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3NT  O  T7C     H.  OB  -A.  33  Y. 


A  NEW 

Pronouncing  Dictionary  of  Medicine. 


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)eautifully 

his  purpose.     It  will  contain  most  important  tables  of 

Bacilli,  Micrococci,  Leucomaines,  Ptomaines,  etc.  etc., 

the  whole  forming  the  most  complete,  reliable,  and  valuable  I>i< 
ary  in  the  market. 

It  has  been  the  aim  of  the  Publisher  to  place  in  the  hands  of  stu- 
dents and  the  medical  profession  a  work  which  should  contain  the 
names  of  Hundreds  of  New  Words  now  being  adopted,  and  .'it  the  - 
time,  by  leaving  out  the  numerous  obsolete  terms  contained  in  most  Dic- 
tionaries, keep  the  volume  of  such  a  size  as  to  be  most  convenient  for 
ready  reference. 


SAUNDERS'  QUESTION-COMPENDS, 

/ 


ESSENTIALS  OF  GYNECOLOGY. 


ARRANGED    IN    THE    FIIKM    OF 


QUESTIONS  AND  ANSWERS 


PREPARED    ESPECIALLY    FOR 


STUDENTS  OF  MEDICINE. 


BY 

EDWIN   B.   CRAGIN,   M.D., 

r    '   ' 

ATTENDING    GYNECOLOGIST    TO     THE    ROOSEVELT    HOSPITAL,    OUT-PATIENT    DLr  ARTM  KNT 
ASSISTANT  SURGEON   TO  THE   NEW   "YORK   CANCER   HOSPITAL,    ETC 


WITH  58  ILLUSTRATIONS. 


THIRD  EDITION. 


PHILADELPHIA: 

W.    B.    SAUNDERS, 

913  Walnut   Stricet, 

1893. 


1^3 


Entered  according  to  Act  of  Congress,  in  the  year  1890,  by 

W.   B.   SAUNDERS, 

In  the  Office  of  the  Librarian  of  Congress,  at  Washington,  D.  C. 


PRESS  OF 

Edward  Stern  &  Co. 

PHILADELPHIA. 


o 

o 


PREFACE. 


No  one  appreciates  more  fully  than  the  Author  the  inadequacy  of 
this  little  work  for  a  thorough  study  of  Gynaecology.  This  has  not 
been  the  aim.  He  only  hopes  that  as  a  means  of  review  and  as  a 
summary  of  the  results  of  more  extensive  reading,  the  student  may 
find  the  work  of  some  value.  The  Author  wishes  also  to  state  that 
in  its  compilation  he  has  freely  consulted,  and  made  use  of,  the 
standard  works  of  Hart  and  Barbour,  Thomas,  Schroeder,  The 
American  System  of  Gynaecology,  notes  on  the  lectures  of  Prof. 
Geo.  M.  Tuttle  at  the  College  of  Physicians  and  Surgeons,  New 
York,  and  numerous  journals. 

E.  B.  C. 


CONTENTS. 


PAGE 

Mons  Veneris, 17 

Labia  Majora, 17 

Labia  Minora, 18 

Clitoris, 18 

Vestibule, 20 

Fourcbette,      20 

Fossa  Navicularis,      20 

Bulbs  of  tbe  Vagina, 20 

Vulvovaginal  Glands, 21 

Hymen, 21 

Vagina, 21 

Uterus, 23 

Mucous  Membrane  of  Uterus, 25 

Fallopian  Tubes, 30 

Ovaries, 31 

Parovarium, 34 

Urinary  Tract, 34 

Bladder, 35 

Rectum, 37 

Pelvic  Floor, 39 

Perineal  Body, 40 

Muscles  of  the  Perineum, 41 

Ischio-rectal  Fossa, 41 

Development  of  Pelvic  Organs, 42 

Physical  Examination  of  Pelvic  Organs, 42 

Vaginal  Examination, 43 

Bimanual  Examination, 45 

Pectal  Examination,      46 

Instruments, 48 

Specula, 48 

The  Sims  Speculum, 48 

v 


VI  CONTEXTS. 

PAGE 

Instruments,  the  Fergussou  Speculum,      50 

The  Brewer  Speculum, 51 

Volsella, 52 

Uterine  Sound, 53 

Uterine  Probe,      57 

Dilators, 57 

Tents, 57 

Graduated  Hard  Dilators,      59 

Elastic  Dilators, 61 

The  Curette, 61 

Vulvitis, 62 

Acute  Simple  Catarrhal, , 63 

Chronic  Catarrhal, 63 

Gonorrheal, 64 

Phlegmonous, 65 

Diphtheritic, 66 

Gangrenous, 66 

Follicular,      67 

Cyst  and  Abscess  of  Vulvo-vaginal  Gland, 68 

Pudendal  Hernia, 69 

Pudendal  Hseniatocele,    .        70 

Hemorrhage  from  Vulva, 71 

Skin  Diseases  of  the  Vulva, 72 

Erythema  of  the  Vulva, 72 

Eczema  of  the  Vulva, 72 

New  Growths  of  the  Vulva, 74 

Simple  Papillomata, 74 

Pointed  Condylomata, 74 

Syphilitic  Condylomata, 75 

Pruritus  Vulva?, 75 

Hyperesthesia  of  the  Vulva, 77 

Vaginismus, 77 

Coccygodynia, 78 

Irritable  Urethral  Caruncle, 79 

Prolapse  of  Urethral  Mucous  Membrane, 80 

Malformations  of  the  Vulva, 80 

Diseases  of  the  Vagina, 81 

Simple  Catarrhal  Vaginitis, 81 

Gonorrhoea!  Vaginitis, 82 


CONTENTS.  Vll 

PAGE 

Diseases  of  the  Vagina,  Ulcerative  Vaginitis, 83 

Diphtheritic  Vaginitis, 84 

Pelvic  Peritoneum,      84 

Pelvic  Peritonitis, 85 

Pelvic  Cellulitis, 87 

Pelvic  Hematocele  and  Hematoma, 91 

Menstruation, 96 

Disorders  of  Menstruation, 96 

Amenorrhcea, 96 

Vicarious  Menstruation, 98 

Menorrhagia  and  Metrorrhagia, 98 

Dysmenorrhcsa, 99 

Obstructive, 100 

Congestive, 100 

Neuralgic, 101 

Ovarian, 102 

Membranous, 102 

Malformations  of  the  Vagina, 104 

Atresia  of  the  Vagina, 104 

Malformations  of  the  Uterus, 106 

Displacements  of  the  Uterus, 110 

Anteversion, Ill 

Anteflexion, 112 

Retroversion  and  Retroflexion,      115 

Pessaries, 119 

Alexander's  Operation, 123 

Hysterorrhaphy, 124 

Prolapsus  Uteri, 124 

Laceration  of  Perineum  and  Relaxation  of  Vaginal  Outlet,  .    .    .  127 

Saenger-Tait  Operation, 128 

Emmet's  Operation, 132 

Hypertrophy  of  the  Cervix, 134 

Stenosis  of  the  Cervix, 135 

Laceration  of  the  Cervix, 136 

Trachelorrhaphy,      139 

Endometritis, 140 

Acute  Endometritis, 141 

Chronic  Endometritis, 142 

Metritis, 146 


Vlll  CONTENTS. 

PAGE 

Metritis,  Acute  Metritis, 147 

Chronic  Metritis,      148 

Atrophy  of  the  Uterus, 151 

Fibroid  Tumors  of  the  Uterus, 151 

Inversion  of  the  Uterus, 158 

Polypi, ( 163 

Carcinoma  Uteri , 167 

Vaginal  Hysterectomy, 169 

High  Amputation  of  the  Cervix, 170 

Sarcoma  of  the  Uterus, 171 

Salpingitis, 172 

Affections  of  the  Ovaries, 174 

Hemorrhage  into  the  Ovaries, 174 

Ovaritis, 175 

Prolapse  of  the  Ovary, 178 

Tumors  of  the  Ovary, 179 

Parovarian  Cysts, 184 

Extra-uterine  Gestation, 186 

Fistulae, 188 

Recto-vaginal  Fistula, 190 


ESSENTIALS  OF  GYNECOLOGY. 


What  is  included  in  the  term  external  genitals  ? 

That  portion  of  the  genital  tract  which  is  visible  when  the  patient 
is  in  the  dorsal  position,  with  knees  elevated  and  the  labia  separated 
with  the  fingers,  viz.  :  Mons  Veneris,  Labia  Majora,  Labia  Minora, 
Clitoris,  Vestibule,  Fourchette  and  Fossa  Navieularis. 

What  other  terms  are  in  common  use  for  the  external 
genitals  ? 

Pudendum  and  Vulva. 

The  term  vulva  is  inexact,  as  it  originally  applied  to  the  labia, 
nevertheless  it  is  in  common  use. 

What  comprise  the  internal  organs  of  generation  ? 

The  Uterus,  Fallopian  tubes  and  Ovaries. 

The  Vagina  connects  the  external  with  the  internal  generative 
organs. 

Budin  regards  the  Hymen  as  anatomically  a  folding  in  of  the 
vaginal  walls. 

Mons  Veneris. 
Describe. 

The  Mons  Veneris  is  a  triangular  projection,  or  cushion  of  adipose 
tissue,  situated  over  the  symphysis  pubis.  Anatomically,  in  addition 
to  adipose  tissue,  it  contains  fibrous  and  elastic  tissue.  After 
puberty  it  is  covered  with  hair,  which  has  a  tendency  to  curl,  and 
is  usually  somewhat  darker  than  the  hair  of  the  head.  Numerous 
sebaceous  and  sweat  glands  are  present. 

Labia  Majora. 

Describe  them. 

The  labia  majora  are  two  folds  of  skin  which  extend  from  the 
mons  veneris  in  front  to  meet  in  the  fourchette  posteriorly ;  they 
2  17 


18  ESSENTIALS   OF  GYNAECOLOGY. 

are  covered  externally  with  coarse  hair,  and  richly  supplied  with 
sebaceous  and  sweat  glands ;  they  also  contain  adipose,  fibrous  and 
elastic  tissue.  Above,  the  round  ligament  can  be  traced  into  thein  on 
either  side  ;  also  the  remains  of  the  canal  of  Nuck,  which  sometimes 
continues  pervious  and  admits  of  hernia.  The  inner  surface  of  the 
labia  is  smooth,  and  somewhat  resembles  mucous  membrane,  a  few 
fine  hairs,  however,  are  visible  on  close  inspection. 

The  labia  majora  in  the  virgin  lie  in  contact ;  in  old  women  they 
become  atrophied  and  allow  the  labia  minora  to  protrude. 

The  arterial  supply  is  the  superficial  perineal  branch  of  the  internal 
pudic  The  veins  communicate  with  the  bulbs  of  the  vagina  and 
take  the  course  of  the  arteries.  The  lymphatics  empty  into  the 
inguinal  glands.  The  nerve  supply  is  from  the  superficial  perineal 
branches  of  the  internal  pudic. 


Labia  Minora. 

Describe. 

The  labia  minora,  or  nymphae,  are  two  folds  of  muco-cutaneous 
tissue  which  arise  about  the  middle  of  the  labia  majora  on  their 
inner  surfaces,  and  extending  upward  divide  into  two  portions ;  the 
two  lower  uniting  just  below  the  clitoris  to  form  the  fteenuni,  the 
two  upper  just  above  the  clitoris  to  form  the  prepuce.  The  venous 
supply  is  rich  ;  it  communicates  with  the  bulbs  of  the  vagina  and 
with  the  pudic  and  perineal  veins.  The  arterial  supply,  nerves  and 
lymphatics  are  the  same  as  for  the  labia  majora.  The  sebaceous 
glands  are  very  abundant. 

Clitoris. 

Describe. 

The  clitoris,  the  analogue  of  the  penis  in  the  male,  is  situated  at 
the  apex  of  the  vestibule;  it  consists  of  a  glans,  a  body  and  two 
crura. 

The  glans.  the  only  part  visible,  is  a  mass  of  erectile  tissue,  about 
the  size  of  a  small  pea,  very  abundantly  supplied  with  nerves  and 
partially  covered  by  its  prepuce. 

The  body  also  consists  of  erectile  tissue  ;  it  is  about  an  inch  long, 
surrounded  by  a  firm  fibrous  covering,  and  shown,  on  section,  to 


CLITORIS.  19 

consist  of  two  halves,  corpora  cavernosa,  separated  by  an  imperfect 
septum. 

The  crura  are  two  prolongations  of  erectile  tissue  with  a  dense 
fibrous  sheath;  they  arise  from  the  anterior  borders  and  inner  sur- 
faces  of  the  pubic  and  ischiatic  rami,  and  extend  forward  to  unite 
in  the  body  just  beneath  the  pubic  arch. 

Give  the  vascular  supply  of  the  clitoris. 

The  arterial  Supply  is  from  the  two  terminal  branches  of  the  in- 
ternal pudie.  The  blood  is  returned  by  the  dorsal  vein  which  empties 
into  the  vesical  plexus. 

Describe  the  lymphatics  of  the  clitoris. 

The  clitoris  is  surrounded  by  a  plexus  of  lymphatics  which  termi- 
nate in  the  inguinal  glands. 

Describe  the  nerve  supply  of  the  clitoris. 

The  clitoris  receives  numerous  filaments  both  from  the  sympa- 
thetic system  and  from  the  pudic  nerve. 

According  to  Savage,  "small  as  this  organ  is  compared  with  the 

penis,  it  has  in  proportion  four  or  five  times  the  nervous  supply  of 
the  latter." 

What  are  the  differences  between  the  clitoris  and  the  penis  ? 

The  clitoris  has  neither  corpus  spongiosum  nor  urethra,  both  of 
which  are  present  in  the  penis. 

What  are  the  points  of  resemblance  between  the  clitoris  and 
the  penis  ? 

They  are  both  erectile. 

They  each  consist  of  a  glans,  a  body  and  two  crura. 

They  each  have  two  corpora  cavernosa  separated  by  an  incomplete 
septum.  The  glans  in  each  is  partly  covered  by  a  prepuce,  with 
its  i  Vacuum  attached  below. 

What  do  we  find  in  the  female  as  the  analogue  of  the  corpus 
spongiosum  in  the  male  ? 
The  bulbs  of  the   vagina   and  the   labia   minora,   which,   in   the 
female,   lie  at  the  side  of  the  urethra,  correspond  to  the  corpus 
spongiosum  in  the  male. 


20  ESSENTIALS   OF  GYNAECOLOGY. 

What  in  the  male  is  the  analogue  of  the  labia  major  a  in 
the  female? 
The  scrotum. 

Vestibule. 

Describe. 

The  vestibule  is  a  triangular  area  covered  with  mucous  membrane, 
in  the  base  of  which  is  situated  the  meatus  urinarius  ;  the  apex  lies 
just  below  the  clitoris  ;  the  sides  are  formed  by  the  inner  edges  of 
the  labia  minora,  the  base  by  the  upper  margin  of  the  vaginal 
orifice.  Beneath  the  mucous  membrane  lies  a  venous  plexus  called 
the  pars  intermedia.  The  vestibule  differs  from  the  labia  and  mons 
veneris  in  having  no  sebaceous  glands. 

Fourchette. 

Describe. 

The  fourchette,  or  posterior  commissure,  is  a  mere  fold  of  skin 
formed  by  the  junction  of  the  labia  majora  at  the  anterior  edge  of 
the  perineum. 

Fossa  Navicularis. 

Describe. 

The  fossa  navicularis  is  a  boat-shaped  cavity  which  is  formed 
between  the  lower  portion  of  the  hymen  and  the  inner  aspect  of 
the  fourchette,  when  the  latter  is  pulled  down  with  the  finger,  or 
the  labia  are  separated. 

When  the  parts  are  at  rest,  no  such  hollow  exists. 

Bulbs  of  the  Vagina. 

Describe  them. 

The  bulbs  of  the  vagina  are  two  oval  masses  of  erectile  tissue 
situated  on  either  side  of  the  ostium  vaginae  and  base  of  the  vesti- 
bule ;  posteriorly,  they  lie  in  contact  with  the  anterior  layer  of  the 
triangular  ligament ;  they  are  partially  covered  in  front  by  the  bulbo- 
cavernosi  muscles  ;  they  extend  as  high  as  the  meatus  urinarius.  and 
are  connected  by  the  pars  intermedia  with  the  cavernous  tissue  of 
the  clitoris.  Their  size  varies  greatly  from  that  of  a  bean,  as  given 
by  Hart  and  Barbour,  to  a  mass  an  inch  and  a  half  long. 


VAGINA.  21 


Vulvo-Vaginal  Glands. 

describe. 

The  vulvovaginal,  or  Bartholinian  glands  are  small  oval  bodies 
about  the  size  of  an  almond,  lying  just  behind  the  lower  extremities 
of  the  bulbs  ;  they  lie  behind  the  anterior  layer  of  the  triangular 
ligament,  and  eaeh  gland  has  a  duct  about  half  an  inch  in  length 
which  opens  just  in  front  of  the  hymen  on  each  side. 

They  secrete  a  glairy  mucus  which  lubricates  the  parts. 


Hymen. 

Describe. 

The  hymen  is  a  fold  of  mucous  membrane  which  surrounds  the 
ostium  vaginae  ;  it  has  a  connective  tissue  framework,  and  contains 
blood  vessels  and  nerves. 

According  to  Budin,  it  is  an  infolding  of  the  entire  vaginal  wall. 

The  hymen  may  be  of  several  forms  ;  the  most  common  being  the 
crescentic.  Other  forms  are  the  annular,  making  a  ring  about  tfie 
ostium  ;  the  cribriform,  perforated  by  numerous  small  holes ;  and 
the  fimbriated,  with  a  fringed  edge.  It  is  sometimes  imperforate, 
a  pathological  condition. 

What  value  has  the  hymen  as  a  criterion  of  chastity  ? 

Very  slight,  as  neither  is  its  absence  proof  that  intercourse  has 
taken  place,  nor  is  its  presence  an  absolute  proof  to  the  contrary. 

What  are  the  carunculse  myrtiformes  ? 

They  were  formerly  regarded  as  the  remains  of  the  hymen,  but 
are  now  considered  the  tags  resulting  from  the  laceration,  sloughing 
and  cicatrization  incident  to  childbirth. 


Vagina. 

Describe. 

The  vagina  is  spoken  of  by  Hart  and  Barbour  as  "  a  mucous  slit  in 
the  pelvic  floor;"  it  is  the  canal  connecting  the  uterus  and  the 
vulva,  lying  between  the  bladder  and  urethra  in  front  and  the 
rectum  behind ;  its  walls,  which  are  anterior  and  posterior,  are 
normally  in  contact. 


22  ESSENTIALS   OF   GYNECOLOGY. 

The  anterior  wall  measures  2-2£  inches  in  length,  the  posterior 
3-3J  inches.  The  anterior  wall  is  shorter  than  the  posterior,  fr<  >m 
the  fact  that  the  uterus  is  set  into  the  anterior  wall. 

The  vagina  is  very  dilatable,  and  when  distended  is  conical  in 
shape,  being  much  more  roomy  above  than  below. 

The  vaginal  walls  on  section  are  seen  to  consist  of  three  layers : 
1,  mucous  ;  2,  muscular  ;  3,  connective  tissue. 

The  mucous  membrane  on  both  anterior  and  posterior  walls  presents 
at  the  lower  portion  of  the  canal  numerous  ridges  or  rugae,  extending 
transversely  from  a  central  column  ;  the  anterior  being  the  more 
distinct.  The  epithelium  covering  the  mucous  membrane  is  of  the 
squamous  variety. 

The  muscular  coat  consists  of  two  layers  of  unstriped  muscle,  the 
inner  being  longitudinal  (Henle)  and  the  outer  circular. 

The  outer  coat  is  of  connective  tissue,  and  contains  the  external 
plexus  of  veins. 

The  roof,  or  fornix  of  the  vagina,  that  portion  of  the  canal  sur- 
rounding the  cervix,  is,  for  convenience,  divided  into  four  portions  : 
the  anterior  fornix,  the  posterior  fornix,  and  the  lateral  fornices ; 
of  these  the  posterior  is  the  deeper.  A  very  few  mucous  glands  are 
found  in  the  vagina.     The  secretion  is  an  acid  mucus. 

What  is  the  arterial  supply  of  the  vagina  ? 

The  arterial  supply  is  from  the  vaginal  arteries,  which  supply  the 
lateral  walls  ;  branches  of  the  uterine  arteries  supplying  the  upper 
extremity,  and  branches  of  the  pudendal  arteries  supplying  the  lower 
extremity.  These  anastomose  with  each  other  and  with  the  vesical 
and  rectal  arteries. 

Describe  the  veins  of  the  vagina. 

The  vaginal  veins  form  plexuses  which  surround  the  canal  like 
sheaths ;  one  being  external  to  the  muscular  layer,  the  other  just 
beneath  the  mucous  membrane. 

''These  communicate  freely  with  the  pudendal,  vesical  and  hemor- 
rhoidal plexuses  below,  and  with  the  plexuses  of  the  broad  ligament 
above."     These  veins  contain  no  valves. 

Describe  the  lymphatics  of  the  vagina. 

The  lymphatics  of  the  lower  fourth  of  the  vagina,  together  with 
those  from  the  external  genitals  enter  the  inguinal  glands. 


UTERUS.  23 

The  lymphatics  from  the  upper  three-fourths  of  the  vagina  join 
with  those  from  the  cervix  and  bladder,  and  enter  the  iliac  glands. 
According  to  Le  Bee,  they  enter  the  obturator  glands. 

Describe  the  nerve  supply  of  the  vagina. 

!  The  vagina  is  supplied  by  branches  of  the  inferior  hypogastric 
plexuses  of  the  sympathetic  system.  These  plexuses  lie  on  either 
side  of  the  vagina. 

Give  the  relations  of  the  vagina. 

The  anterior  vaginal  wall  is  connected  in  its  lower  half  with  the 
urethra,  in  its  upper  half  with  the  neck  and  fundus  of  the  bladder ; 
the  former  connection  is  much  more  intimate  than  the  latter.  The 
posterior  vaginal  wall  in  its  lower  fourth  lies  in  connection  with  the 
perineal  body,  in  its  middle  two-fourths  with  the  rectum,  in  its  upper 
fourth  with  the  cul-de-sac  of  Douglas.  The  anterior  fornix  is  distant 
1}  inches  from  the  utero- vesical  pouch,  and  through  this  fornix  can 
normally  be  felt  the  body  of  the  uterus  and  the  angle  it  makes  with 
the  cervix. 

The  posterior  fornix  is  in  contact  with  the  cul-de-sac  of  Douglas. 
The  lateral  fornices  are  in  relation  with  the  bases  of  the  broad  liga- 
ments, and  through  these  fornices  can  normally  be  felt  the  vessels  of 
the  broad  ligament,  and  occasionally  the  ovary  and  tube  of  that  side. 

The  vagina  makes  an  angle  of  60°  with  the  horizon  when  the 
woman  is  erect. 

Uterus. 

Give  the  gross  anatomy. 

■     The  uterus,  the  organ  of  gestation,  is  a  hollow,  pear-shaped  organ, 

;  flattened  antero-posteriorly,  situated  in  the  pelvis  between  the  bladder 

and  rectum.     It  measures  in  the  virgin  about  3  inches  in  length,  2 

inches  in  breadth,  at  the  level  of  the  Fallopian  tubes,  and  one  inch 

in  thickness.     The  weight  of  the  virgin  uterus  varies  from  1  to  1?  oz. 

It  consists  of  three  portions  :  the  cervix,  body  and  fundus. 

As  viewed  externally,  the  uterus,  on  its  anterior  surface,  is  nearly 
flat,  its  posterior  surface  convex  ;  a  little  below  the  centre  is  a  slight 
constriction  called  the  isthmus. 

The  cervix  is  that  portion  of  the  uterus  below  the  isthmus,  and 
which  projects  in  part  into  the  vagina. 


24 


ESSENTIALS  OF  GYNAECOLOGY. 


The  body  is  that  portion  between  the  isthmus  and  the  line  joining 
the  entrance  of  the  Fallopian  tubes. 

The  fundus  is  the  portion  above  this  line. 

Describe  the  uterine  canal. 

The  uterine  canal  measures  normally  2j  inches,  and  holds  about 
12  drops ;  the  cervical  portion  of  the  canal  is  spindle-shaped  ;  the 
remainder  is  triangular,  with  anterior  and  posterior  walls  in  contact. 

What  are  the  opening's  into  the  uterine  cavity  ? 

There  are  three  :  the  os  externum,  which  communicates  with  the 
vagina  ;  and  the  orifices  of  the  Fallopian  tubes  at  the  upper  angles, 


Diagram  of  Uterus,  to  show  divisions  of  Cervix.    (Schroeder.) 

a,  Infra-vaginal   portion;  b,  Intermediate    portion;    c,  Supra-vaginal  portion;   2*4 

Bladder;  P,  Peritoneum.    The  dotted  line  showB  peritoneum. 


which  connect  the  uterine  with   the   peritoneal  cavity.     The   os 
internum  connects  the  cavity  of  the  cervix  with  that  of  the  body. 

What  divisions  of  the  cervix  are  made  ? 

Schroeder  divides  the  cervix  into  three  portions,  as  seen  from  the 
accompanying  figure,  (Fig.  1 ,  a,  &,  c). 

a.  The  infra-vaginal  portion. 

b.  The  intermediate  portion. 

c.  The  supra-vaginal  portion. 


MUCOUS  MEMBRANE  OF  THE  UTERUS.  25 

The  infra -vaginal  portion  of  the  cervix  (a)  is  that  below  the  level 
of  the  attachment  of  the  anterior  vaginal  wall. 

The  supra-vaginal  portion  (c)  is  that  above  the  level  of  the  attach- 
ment of  the  posterior  vaginal  wall. 

The  intermediate  portion  (b)  is  that  between  the  infra-  and  supra- 
vaginal portions. 

What  portions  of  the  cervix  project  into  the  vagina  ? 

The  infra-vaginal  portion  of  the  anterior  lip,  and  the  infra-vaginal 
and  intermediate  portions  of  the  posterior  lip. 

For  practical  purposes,  it  is  sufficient  to  divide  the  cervix  into  the 
supra-vaginal  portion,  that  above  the  attachment  of  the  vagina ; 
and  the  infra-vaginal,  that  within  the  vagina. 

What  are  the  three  elements  in  the  structure  of  the  uterus  ? 

1.  The  mucous  membrane. 

2.  The  muscular  coat. 

3.  The  peritoneal  coat. 

Mucous  Membrane  of  the  Uterus. 

Describe  that  of  the  cervix. 

The  mucous  lining  of  the  cervix  differs  from  that  of  the  body  of 
the  uterus.  In  the  cervix  it  is  thrown  into  folds  presenting  the 
arbor  vitae  appearance,  there  being  a  central  ridge  on  both  anterior 
and  posterior  walls,  and  from  these  ridges  secondary  ridges  extend- 
ing obliquely. 

The  anterior  and  posterior  ridges  are  not  directly  opposite,  but  fit 
past  one  another.  The  epithelium  is  ciliated  on  the  ridges,  non- 
ciliated  in  the  depressions  (de  Sinety). 

The  mucous  membrane  covering  the  vaginal  portion  of  the  cervix 
closely  resembles  that  of  the  vagina,  consisting  of  vascular  papillae 
covered  by  squamous  epithelium. 

Describe  the  mucous  membrane  of  the  body  of  the  uterus. 

The  mucous  lining  of  the  body  of  the  uterus  is  smooth,  velvety 
and  of  a  grayish  red  color  ;  it  is  directly  connected  with  the  muscu- 
lar coat,  with  no  submucous  layer.  It  averages  about  ^  of  an  inch 
in  thickness,  and  consists  of  columnar,  ciliated  epithelium,  on  a  base 
of  connective  tissue  between  whose  fibres  numerous  lymph  spaces 


26  ESSENTIALS   OP  GYNECOLOGY. 

are  found.  The  mucous  membrane  is  thickly  studded  with  glands, 
the  utricular  glands,  which  penetrate  the  whole  thickness  of  the 
mucous  layer.  These  glands  are  of  the  tubular  variety,  and  are  fre- 
quently bifurcated  at  their  blind  extremities.  They  are  lined  with 
prismatic  ciliated  epithelium,  resting  on  a  thin  membrana  propria. 
Their  direction  is  not  at  right  angles  to  the  surface,  but,  according 
to  Turner,  more  or  less  oblique. 

Describe  the  muscular  structure  of  the  uterus. 

The  muscular  structure  of  the  uterus  is  most  marked  after  im- 
pregnation ;  it  can  then  be  separated  into  three  layers  : — 

1.  The  external,  superficial  or  longitudinal. 

2.  The  middle  or  oblique. 

3.  The  internal  or  circular. 

The  external  layer  is  most  distinct  on  the  anterior  and  posterior 
surfaces,  where  it  is  seen  to  consist  of  fibres  running  up  longitudi- 
nally over  the  fundus  ;  it  sends  fibres  into  the  broad,  round,  ovarian 
and  utero-sacral  ligaments  and  also  into  the  Fallopian  tubes. 

The  middle,  or  oblique  layer  has  no  regular  arrangement ;  some  of 
the  fibres  run  longitudinally,  some  transversely  and  some  obliquely  ; 
they  surround  the  blood  vessels,  and  on  this  account  this  layer  is  of 
great  importance  ;  it  constitutes  the  chief  portion  of  the  uterine  wall. 

The  internal  or  circular  layer  shows  fibres  arranged  in  a  circular 
manner,  most  distinct  around  the  orifices  of  the  Fallopian  tubes  and 
at  the  os  internum. 

Describe  the  peritoneal  coat  of  the  uterus. 

The  peritoneum  covers  the  anterior  surface  of  the  uterus  above 
the  level  of  the  internal  os  ;  it  extends  over  the  fundus,  covers  its 
posterior  surface  as  low  as  the  attachment  of  the  posterior  vaginal 
wall  and  extends  down  the  latter  for  about  an  inch. 

Describe  the  arterial  supply  of  the  uterus. 

The  uterus  is  supplied  by  the  uterine  and  ovarian  arteries,  as  seen 
by  the  accompanying  figure.     (Fig.  2.) 

The  uterine  artery  arises  from  the  anterior  division  of  the  internal 
iliac,  inns  between  the  folds  of  the  broad  ligament  to  about  the 
level  of  the  os  externum,  and  then  turns  upward  along  the  side  of 
the  uterus  to  unite  with  the  descending  branch  oi  the  ovarian  artery  ; 


MUCOUS   MEMBRANE   OF  THE   UTERUS.  It 

it  gives  off  numerous  lateral  branches  to  the  uterus,  anastomosing 
with  those  of  the  opposite  side  ;  these  are  very  tortuous  and  are 
called  the  ' '  curling  arteries  of  the  uterus. ' ' 


Fig.  2. 


Distribution  of  ovarian,  uterine  and  vaginal  arteries  (Ryrtt). 
a,  ovarian  artery;  a' and  &',  branches  to  tube;  c',  branches  to  ovary;  b,  branch  to 
round  ligament;  c,  branch  to  fundus;  d,  branch  to  join  uterine  artery  ;  e,  uterine 
artery ;/,  anterior  branch  of  internal  iliac;  g,  vaginal  arteries  ;  h,  azygos  artery 
of  vagina. 


28  ESSENTIALS  OF  GYNAECOLOGY. 

Sometimes  the  vaginal  artery  springs  directly  from  the  uterine. 

Opposite  the  internal  os,  the  uterine  artery  gives  off  a  branch 
which,  uniting  with  its  fellow  of  the  opposite  side,  surrounds  the 
ceivix  and  is  called  ' '  the  circular  artery. ' ' 

The  ovarian  artery  arises  directly  from  the  aorta,  runs  between  the 
folds  of  the  broad  ligament,  at  its  upper  part,  to  the  upper  angle  of 
the  uterus;  it  gives  off  a  few  large  vessels  to  the  outer  extremity  of 
the  tube,  and  then  a  number  of  very  tortuous  vessels  which  sur- 
round the  ovary. 

Just  before  reaching  the  uterus,  it  gives  off  a  number  of  branches 
to  the  proximal  extremity  of  the  tube  and  one  to  the  round  liga- 
ment. 

At  the  angle  of  the  uterus  it  divides  into  two  branches  ;  one  sup- 
plies the  fundus  and  anastomoses  with  its  fellow  of  the  opposite 
side ;  the  other  descends  along  the  side  of  the  uterus  and  anasto- 
moses with  the  uterine  artery. 

The  arterial  supply  of  one  side  alone  has  been  described,  but  the 
description  applies  equally  well  to  the  other  side. 

Describe  the  venous  supply  of  the  uterus. 

The  uterus  is  surrounded  beneath  the  peritoneum  by  a  plexus  of 
veins,  called  the  uterine  plexus  ;  this  receives  the  blood  from  the 
uterine  walls  and  communicates  with  the  vaginal  and  vesical  plexuses 
below  and  the  pampiniform  above ;  it  empties  into  the  internal  iliac 
and  ovarian  veins. 

Describe  the  lymphatics  of  the  uterus. 

The  lymphatics  from  the  body  of  the  uterus  join  with  those  from 
the  ovary  and  tube  and  terminate  in  the  lumbar  glands. 

The  lymphatics  from  the  cervix  pass  beneath  the  base  of  the 
broad  ligaments  to  the  hypogastric  glands. 

According  to  Le  Bee,  they  terminate  in  the  obturator  glands. 

Give  the  nerve  supply  of  the  uterus. 

The  chief  nerve  supply  of  the  uterus  is  from  the  inferior  hyp«  >- 
gastric  plexus  of  the  sympathetic. 

The  cervix  also  receives  branches  from  the  Upper  sacral  nerves. 

What  is  the  normal  position  of  the  uterus  ? 

This  question  has  been  frequently  discussed  and  at  great  length. 


MUCOUS  MEMBRANE  OF  THE  UTERUS.  29 

It  is  now  sufficient  for  practical  purposes  to  say  that  the  uterus, 
when  the  pelvic  organs  are  normal  and  when  bladder  and  rectum  are 
empty,  lies  slightly  anteflexed  and  slightly  anteverted  ;  but  the  posi- 
tion is  constantly  changing  with  the  degree  of  distention  of  the  blad- 
der and  rectum,  especially  the  former. 

What  are  the  ligaments  of  the  uterus  ? 

There  are  two  utero-vesical  ligaments,  two  round,  two  broad  and 
two  utero-sacral. 

Describe  the  utero-vesical  ligaments. 

They  are  two  folds  of  peritoneum  passing  between  the  bladder  and 
the  lower  portion  of  the  uterus  on  each  side. 

Describe  the  round  ligaments. 

They  are  two  musculo-fibrous  cords,  4-5  inches  in  length,  which 
extend  from  the  superior  angles  of  the  uterus,  in  the  anterior  folds 
of  the  broad  ligaments  and  below  the  Fallopian  tubes,  forward  and 
outward  to  the  inguinal  canal ;  thence  through  this  canal  where  they 
terminate  in  three  points  of  insertion  :  the  external,  middle  and 
internal.  The  external  blends  with  the  outer  pillar  of  the  ring  near 
Gfimbernat's  ligament.  The  middle  terminates  in  the  upper  portion 
of  the  external  ring.  The  internal  unites  with  the  conjoined  tendon. 
Besides  muscular  and  fibrous  tissue,  these  ligaments  contain  areolar 
tissue,  vessels  and  nerves. 

They  are  of  importance  as  being  those  shortened  in  Alexander's 
operation. 

Describe  the  broad  ligaments. 

They  are  two  folds  of  peritoneum  which  extend  from  the  sides  of 
the  uterus  to  the  wall  ot  the  pelvis,  ' '  along  a  line  which  is  situ- 
ated between  the  great  sacro-sciatic  notch  and  the  margin  of  the 
obturator  foramen  as  far  down  as  the  level  of  the  ischial  spine. ' ' 
The  inner  and  greater  part  of  its  superior  border,  on  each  side,  is 
occupied  by  the  Fallopian  tube  ;  the  part  of  the  superior  border  not 
so  occupied  is  called  the  infundibulo-pelvic  ligament. 

What  two  folds  are  made  in  the  broad  ligament  in  addition 
to  that  occupied  by  the  Fallopian  tube  ? 

An  anterior  fold  caused  by  the  round  ligament  and  a  posterior  fold 
caused  by  the  ovarian  ligament. 


30  ESSENTIALS   OF  GYNECOLOGY. 

Describe  the  ovarian  ligament. 

It  is  a  fibro-muscularcord  about  an  inch  in  length,  which  connects 
the  ovary  with  the  side  of  the  uterus,  just  below  the  entrance  of  the 
Fallopian  tube.  It  lies  in,  and  is  surrounded  by,  the  posterior  fold 
of  the  broad  ligament. 

What  are  contained  between  the  folds  of  the  broad  ligament 
on  either  side  ? 

The  round  ligament,  Fallopian  tube,  ovarian  ligament,  the  paro- 
varium, cellular  tissue,  uterine  and  ovarian  arteries,  the  pampiniform 
plexus  and  other  veins,  numerous  lymphatics  and  nerves. 

The  ovary  is  attached  to  the  anterior  fold  of  the  broad  ligament 
and  projects  through  the  posterior  fold. 

Describe  the  ntero-sacral  ligaments. 

They  are  folds  of  peritoneum  containing  muscular  and  cellular  tis- 
sue, which  extend  from  the  lower  part  of  the  sides  of  the  uterus, 
backward  and  outward  to  the  second  sacral  vertebra. 

What  is  the  meaning  of  the  term  "uterine  appendages,"  as 
usually  employed  ? 
The  Fallopian  tubes  and  ovaries. 

Fallopian  Tubes. 

Describe  them. 

They  are  two  tubes  3-5  inches  in  length,  which  extend  laterally 
from  the  superior  angles  of  the  uterus  ;  they  lie  within  the  folds  of 
the  broad  ligaments,  and  their  direction  is  first  outward,  then  for- 
ward, backward  and  inward  toward  the  ovary. 

They  are  divided  for  consideration  into  three  portions  :  the  isth- 
mus, the  ampulla  and  the  fimbriated  extremity. 

The  isthmus  is  the  narrowest  portion  ;  it  measures  about  an  inch 
in  length,  and  extends  from  the  angle  of  the  uterus  directly  outward, 
joining  the  ampulla  ;  its  lumen  is  only  large  enough  to  admit  a  fine 
bristle. 

The  ampulla  is  the  curved,  dilated  portion  of  the  tube  :  its  lumen 
admitting  an  ordinary  uterine  sound. 

The  fimbriated  extremity  (infundibulum)  is  the  expanded,  funnel- 
shaped  outer  end,  which  is  surrounded  by  fringe-like  processes  (fim- 


OVARIES.  81 

briae),  both  primary  and  secondary,  the  latter  arising  from  the 
former,  which  are  4-5  in  number.  The  longest  of  the  primary 
fimbriae  lies  to  the  inner  side,  is  grooved,  and  is  attached  to  the 
ovary  ;  this  is  called  the  fimbria  ovarica. 

The  tubes,  on  section,  are  seen  to  consist  of  four  layers  or  coats  ; 
the  peritoneal  coat ;  two  muscular  coats,  the  outer  being  longitudinal, 
the  inner  circular  ;  and  a  mucous  coat. 

There  is  no  submucous  layer. 

The  mucous  membrane  is  thrown  into  longitudinal  folds  ;  the  epi- 
thelium is  columnar  and  ciliated. 

Give  the  arterial  supply  of  the  Fallopian  tubes. 

The  Fallopian  tubes  are  supplied  by  the  ovarian  arteries,  which 
send  branches  directly  to  the  outer  and  inner  portions  of  the  tube 
and  supply  the  middle  third  through  branches  from  the  plexus 
about  the  ovary. 

Describe  the  veins,  lymphatics  and  nerve  supply  of  the  Fal- 
lopian tubes. 

The  veins  of  the  tubes  enter  the  pampiniform  plexus  on  either 
side. 

The  lymphatics  join  with  those  from  the  upper  part  of  the  uterus 
and  from  the  ovary,  and  terminate  in  the  lumbar  glands. 

The  nerve  supply  is  from  the  inferior  hypogastric  plexuses. 

What  is  the  supposed  direction  of  the  current  in  the  motion 

of  the  ciliae  of  the  epithelium  in  the  uterus  and  tubes  ? 

In  both  cases  toward  the  fundus ;    in   the  uterus,  from    below 

upward ;    in  the  tubes,  from  the  fimbriated  extremity  toward  the 

uterus. 

Ovaries. 

Give  their  gross  anatomy. 

The  ovaries  are  two  ' '  flattened  ovoid  ' '  bodies  lying  in  the  plane 
of  the  brim  of  the  pelvis,  on  either  side  of  the  uterus.  According 
to  Coe,  they  are  attached  to  the  anterior  folds  of  the  broad  liga- 
ments, and  project  through  the  posterior.  They  are  situated  below 
the  outer  extremities  of  the  tubes. 

They  present  for  consideration  two-  borders,  an  anterior  and  pos- 


32  ESSENTIALS  OF  GYNAECOLOGY. 

terior ;  two  surfaces,  a  superior  and  an  inferior  ;  and  two  extremi- 
ties, an  outer  and  an  inner. 

The  anterior  border  is  nearly  straight ;  the  posterior  is  convex. 

The  anterior  border  is  called  the  hilum,  and  serves  for  the  en- 
trance of  blood  vessels  and  nerves. 

The  superior  surface  is  nearly  flat ;  the  inferior  is  convex. 

The  outer  extremity  is  broad  and  convex  ;  the  inner  is  narrow  and 
tapers  into  the  ovarian  ligament. 

An  ovary  averages  about  1 J  inches  in  length,  f  of  an  inch  in 
breadth  and  ?  an  inch  in  thickness;  it  weighs  about  87  grains. 

Give  the  minute  anatomy  of  the  ovary. 

The  ovary,  on  section,  is  seen  to  consist  of  a  medullary  and  cor- 
tical portion  ;  the  former  being  more  vascular  and  of  a  softer  con- 
sistency than  the  latter.  The  microscope  shows  connective  tissue 
with  numerous  Graafian  follicles  scattered  through  it,  blood  vessels, 
lymphatics,  nerves  and  unstriped  muscular  fibres. 

The  ovary  is  usually  regarded  as  covered  by  a  layer  of  short 
columnar  epithelium,  "germinal  epithelium,"  from  which  the  primi- 
tive ova  are  supposed  to  spring.  (Tait,  on  the  other  hand,  regards 
the  ovary  as  entirely  covered  by  peritoneum. ) 

The  layer  of  ' '  germinal  epithelium  ' '  rests  on  a  thin,  dense  mus- 
culo-fibrous  layer,  called  the  tunica  albuginea. 

The  Graafian  follicles  are  small  vesicular  bodies,  more  numerous 
and  smaller  in  the  cortex  than  in  the  medulla,  with  the  exception  of 
a  few  which  have  matured  and  have  approached  the  surface  of  the 
ovary  from  the  medulla. 

Foulis  estimates  that  at  birth  each  human  ovary  contains  not  less 
than  30,000  Graafian  follicles  (Playfair). 

Give  the  structure  of  a  Graafian  follicle. 

On  examining  a  Graafian  follicle  from  without  inward,  we  find 
the  following  structures  see  (Fig.  3)  :  — 

The  tunica,  fibrosa,  which  is  highly  vascular;  within  this  the 
tunica  propria,  of  more  condensed  connective  tissue  ;  within  this  is 
the  membrana  granulosa,  a  layer  of  columnar  epithelium  which 
encloses  the  liquor  foUicult ;  at  one  side  there  is  a  cellular  eminence 
called  the  discus proligerus,  which  encloses  the  ovum.  The  outer 
covering  of  the  ovum  is  the  vitelline  membrane,  or  zona  pellucida, 


OVARIES. 


33 


surrounding  the  viteUvs  or  yelk.  At  one  point  of  the  latter  is  seon 
the  germinal  vesicle,  and  within  this  the  germinal  spot  A  Graafian 
follicle  measures  from  y^q  to  ^  inch  in  diameter  ;  a  germinal  spot 
not  over  -^^  inch. 

Give  the  arterial  and  venous  supply  of  the  ovaries. 

The  ovaries  are  supplied  by  the  ovarian  arteries,  which  arise 
directly  from  the  aorta. 

The  veins  of  the  ovaiy  emerge  at  the  hilum  and  enter  the  collec- 
tion of  veins  called  the  "bulb  of  the  ovary."  This  communicates 
with  the  veins  from  the  Fallopian  tube  and  upper  portion  of  the 

Fig  3. 


Diagrammatic  Section  of  Graafian  Follicle. 
1.  Ovum.     2.  Menibrana  granulosa.     3.    External  membrane  of  Graafian  follicle. 
4.  Its  vessels.    5.  Ovarian  stroma.    6.   Cavity  of  Graafian  follicle.    7.  External 
covering  of  ovary. 

uterus,  forming  a  collection  called  the  pampiniform  or  ovarian 
plexus  ;  from  this  springs  the  ovarian  vein,  which,  on  the  right  side, 
terminates  in  the  inferior  vena  cava,  on  the  left  side,  in  the  left 
renal  vein.  The  left  ovarian  vein  has  no  valve  at  its  termiDation. 
Some  apply  the  term  pampiniform  plexus  to  all  the  veins  in  the 
broad  ligament. 

Give  the  lymphatics  and  nerve  supply  of  the  ovary. 

The  lymphatics  join  with  those  from  the  tube  and  upper  portion 
of  the  uterus  and  terminate  in  the  lumbar  glands.     The  nerve  sup- 
ply is  from  che  inferior  hypogastric  plexus. 
3 


34  ESSENTIALS   OF  GYNAECOLOGY. 

What  is  the  position  of  the  long  axis  of  the  ovary? 

This  question  has  been  much  discussed.  The  long  axis  of  the 
ovary  may  be  regarded  as  lying  a  little  obliquely  to  the  transversa 
axis  of  the  pelvis,  and  with  a  direction  slightly  backward.  His 
describes  the  long  axis  as  vertical,  but  this  does  not  coincide  with 
the  results  of  autopsies  where  the  pelvic  contents  have  been  normal. 

Parovarium. 

Describe  it. 

The  parovarium,  which  is  the  remains  of  the  Wolffian  body,  con- 
sists of  a  series  of  tubes  situated  between  the  folds  of  the  broad 
ligament,  on  either  side  of  the  uterus,  and  lying  between  the  am- 
pulla of  the  tube  and  the  hiluni  of  the  ovaiy. 

One  of  the  tubes  is  horizontal  and  runs  toward  the  uterus  ;  the 
others  are  nearly  vertical,  converging  toward  the  hiluni ;  they  vary 
greatly  in  number,  in  fact,  from  6  to  30. 

The  outer  6-10  have  a  well-marked  lumen  and  are  lined  with 
ciliated  epithelium  ;  those  internal  to  these  are  merely  fine  fibrous 
cords. 

The  horizontal  tube  running  toward  the  uterus  is  called  the  duct 
of  Gartner.  The  parovarium  is  of  pathological  importance,  as  occa- 
sionally the  seat  of  cysts. 

What  in  the  male  corresponds  to  the  parovarium  in  the 
female  ? 

The  epididymis. 

Urinary  Tract. 

Describe  the  urethra. 

The  female  urethra  is  a  musculo-membranous  canal  about  If 
inches  in  length,  imbedded  in  the  anterior  vaginal  wall,  and  extend- 
ing from  the  vestibule  to  the  neck  of  the  bladder  ;  it  runs  upward 
and  backward,  tl  parallel  with  the  plane  of  the  pelvic  brim." 

It  consists  of  three  coats;  the  outer  two  being  muscular,  the 
inner,  mucous  membrane. 

Of  the  muscular  coats,  the  outer  is  circular,  the  inner  longitudi- 
nal. The  mucous  membrane  in  the  lower  portion  of  the  canal  is 
covered  with  squamous  epithelium,  while  higher  up  the  epithelium 
is  transitional,  like  that  of  the  bladder. 


BLADDER.  35 

The  meatus  urinarius,  the  outer  extremity  of  the  urethra,  is  situ- 
ated in  the  median  iine  at  the  base  of  the  vestibule. 

Describe  Skene's  tubules. 

Just  within  the  meatus,  on  each  side,  are  the  openings  of  Skene's 
tubules,  which  he  describes  as  lying  near  the  floor  of  the  urethra, 
just  beneath  the  mucous  membrane,  and  extending  parallel  to  the 
canal  about  three-fourths  of  an  inch.     Then  function  is  unknown. 

Bladder. 

Describe  it. 

The  bladder  is  a  hollow  musculo-membranous  organ,  situated  in 
the  pelvis  ' '  between  the  symphysis  pubis  in  front  and  the  vagina 
and  uterus  behind. ' ' 

The  bladder  presents  for  consideration  a  body,  a  base  or  fundus, 
and  a  neck.  The  body  is  all  that  portion  above  the  lines  joining  the 
ureteric  openings  and  the  centre  of  the  symphysis  pubis. 

All  below  these  lines  is  the  base  or  fundus.  The  portion  of  the 
fundus  between  the  urethral  and  ureteric  orifices  is  the  trigone. 

The  constricted  portion  continuous  with  the  urethra  is  the  neck. 

The  wall  of  the  bladder  consists  of  three  coats  :  a  peritoneal,  a 
muscular  and  a  mucous. 

The  peritoneal  coat  is  found  only  on  the  summit  of  the  bladder 
and  on  the  upper  part  of  the  posterior  surface.  The  muscular  coat 
consists  of  two  layers  :  an  outer  longitudinal  and  an  inner  circular  ; 
the  latter  being  most  marked  around  the  urethral  orifice. 

The  mucous  membrane  consists  of  several  layers  of  transitional 
epithelium  resting  on  a  membrana  propria  ;  the  superficial  cells  are 
squamous. 

The  mucous  membrane  is  thrown  into  numerous  folds,  except  at 
the  trigone,  where  it  is  more  closely  connected  with  the  underlying 
tissue. 

The  mucous  membrane  is  supported  by  a  submucous  layer  of  fibrous 
and  elastic  tissue,  containing  blood  vessels,  lymphatics  and  nerves. 

What  is  the  arterial  supply  of  the  bladder  and  urethra  ? 

The  bladder  receives  its  arterial  supply  from  the  superior,  middle 
and  inferior  vesical,  and  from  branches  of  the  uterine  and  vaginal 
arteries. 


36  ESSENTIALS   OF  GYNECOLOGY. 

They  are  all  derived  from  the  anterior  division  of  the  internal 
iliac. 
The  urethra  is  supplied  by  branches  from  the  vaginal  arteries. 

What  is  the  venous  supply  of  the  bladder  and  urethra  ? 

' '  The  veins  form  a  complicated  plexus  round  the  neck,  sides  and 
base  of  the  bladder. ' '     (Gray. ) 

This  is  called  the  vesical  plexus  ;  it  lies  external  to  the  muscular 
coat  and  terminates  in  the  internal  iliac  vein. 

The  urethra  is  surrounded  by  a  venous  plexus  which  communi- 
cates with  the  vaginal  plexus. 

Give  the  lymphatic  and  nerve  supply  of  the  bladder  and 
urethra. 

The  lymphatics  of  the  bladder  and  urethra  empty  into  the  hypo- 
gastric glands.  Their  nerve  supply  is  derived  from  the  inferior 
hypogastric  plexuses  of  the  sympathetic  system,  and  from  the  3d 
and  4th  sacral  nerves  of  the  cerebro-spinal  system. 

What  are  the  principal  venous  plexuses  of  the  pelvis  ? 

The  vaginal  plexuses. 

The  vesical  plexus. 

The  hemorrhoidal  plexus. 

The  uterine  plexus. 

The  pampiniform,  or  ovarian  plexus. 

The  bulb  of  the  ovary. 

Describe  the  course  of  the  ureters  in  the  pelvis.    . 

The  ureters  cross  the  external  iliacs  just  beyond  the  bifurcation  of 
the  common  iliacs  ;  they  then  pass  downward  and  outward  along  the 
lateral  walls  of  the  pelvis,  enter  the  broad  ligaments  and  run  forward 
and  inward.  At  the  level  of  the  internal  os  they  are  crossed  by  the 
uterine  arteries  (see  Fig.  4),  and  are  there  situated  about  half  an  inch 
from  the  uterus.  They  pass  alongside  of  the  vagina  a  little  way, 
converge  still  more,  enter  the  vesico-vaginal  septum  and  pierce  the 
bladder  a  little  above  the  middle  of  the  anterior  vaginal  wall ;  they 
are  here  separated  two  inches  from  each  other  and  one-half  to  three- 
fourths  of  an  inch  from  the  cervix, 


RECTUM. 


37 


Rectum. 

Describe. 

The  rectum  is  the  lower  extremity  of  the  large  intestine,  about  8 
inches  in  length,  extending  from  near  the  left  sacro-iliac  synchron- 
drosis  to  terminate  in  the  anus  between  the  coccyx  and  perineum. 

Fig.  4. 


Drawing  from  a  dissection  made  to  show  relations  of  ureters,  uterine  arteries, 
bladder,  etc.    (J.  Greig  Smith.) 
ur.,  ureter;  ut.Ar.,  uterine  artery;  ou ,  os  uteri  exposed  by  an  incision,  x,  made 
through  the  top  of  the  vagina  ;  bl.,  bladder,  the  walls  of  which  are  cut  down  to  the 
insertion  of  the  ureters  into  its  base,  Vag  ,  vagina. 


It  presents  three  curves  : — 

1.  Downward,  backward  and  inward  to  the  3d  sacral  vertebra. 

2.  Forward  to  the  apex  of  the  perineum. 

3.  Backward  to  the  anus. 

The  rectum  is  invested  by  peritoneum  at  its  upper  part. 


38  ESSENTIALS   OF  GYNECOLOGY. 

It  consists  of  a  mucous  and  a  submucous  layer  and  two  muscular 
layers — a  longitudinal  and  a  circular,  the  former  being  external. 

The  mucous  membrane  is  covered  with  columnar  epithelium  and 
contains  numerous  follicles  of  Lieberkiihn. 

At  its  lower  portion  the  mucous  membrane  is  thrown  into  perpen- 
dicular folds  called  columns  of  Morgagni ;  the  depressions  between 
them  being  called  the  sinuses  of  Morgagni. 

There  are  three  oblique  folds  of  importance,  including  not 
only  the  mucous  and  submucous  layers,  but  part  of  the  muscular 
coat. 

One  projects  from  the  anterior  wall  1 J  inches  from  the  anus. 

Another  is  on  the  right  side  near  the  sacral  promontory,  and  a 
third  is  situated  midway  between  the  two,  on  the  left  side. 

The  external  orifice  is  guarded  by  the  sphincter  ani  muscle  which 
surrounds  the  canal,  and  is  inserted  into  the  coccyx  behind  and  the 
perineum  in  front. 

Give  the  vascular  and  nerve  supply  of  the  rectum. 

The  arterial  supply  of  the  rectum  is  from  the  superior,  middle 
and  inferior  hemorrhoidal  arteries.  The  veins  form  a  plexus  beneath 
the  mucous  membrane  which  communicates  with  another  surround- 
ing the  exterior  of  the  canal ;  from  this  spring  veins  corresponding 
to  and  accompanying  the  arteries. 

The  superior  hemorrhoidal  vein  empties  into  the  inferior  mesen- 
teric of  the  portal  system. 

The  middle  and  inferior  hemorrhoidal  empty  into  the  internal 
iliac  of  the  general  venous  system.. 

The  lymphatics  terminate  in  the  sacral  glands. 

The  nerves  are  derived  from  the  hypogastric  and  sacral  plexuses. 

Give  the  relations  of  the  rectum. 

At  its  upper  portion  the  rectum  is  surrounded  by  peritoneum  and 
lies  in  direct  relation  anteriorly  with  the  cul-de-sac  of  Douglas. 

At  about  3  inches  from  the  anus  the  peritoneum  leaves  the  rectum, 
which  then  lies  loosely  attached  to  the  posterior  wall  of  the  vagina 
for  l£  inches. 

The  remainder  is  separated  from  the  vagina  by  the  perineal  body. 

Posteriorly,  the  rectum  is  connected  at  its  upper  part  by  the  rneso- 


PELVIC  FLOOR.  39 

rectum  to  the  sacrum  ;    at  its  lower  part  by  fibrous  tissue  to  the 
sacrum  and  coccyx. 

On  each  side  it  receives  the  insertion  of  the  levatores  ani  and  is 
surrounded  below  by  the  sphincter  ani. 


Pelvic  Floor. 

Describe  the  segments  of  the  pelvic  floor. 

According  to  Dr.  Hart,  the  pelvic  floor  consists  of  two  segments  : 
the  pubic  and  sacral;  the  pubic  consisting  of  the  bladder,  urethra, 
bladder  peritoneum  and  the  anterior  vaginal  wall ;  the  sacral  com- 
prising the  rectum,  perineal  body  and  posterior  vaginal  wall. 

According  to  the  same  authority,  also,  the  pubic  segment  is  made 
up  of  loose  tissue,  loosely  attached  to  the  pubes,  and  is  drawn  up 
during  labor  ;  the  sacral  segment  is  made  up  of  dense  tissue,  closely 
attached  to  sacrum  and  coccyx,  and  is  driven  down  during  labor. 

Describe  the  muscles  and  fascia  of  the  pelvic  floor,  as  dis- 
sected from  above. 

On  examining  the  pelvic  floor  from  abo'.e,  we  find  the  pelvic  fascia 
attached  laterally  to  the  brim  of  the  pelvis,  to  the  spine  of  the 
ischium  behind,  to  the  lower  portion  of  the  symphysis  pubis  in 
front,  and  to  a  tendinous  band — ' '  white  line  " — joining  the  two  latter 
points.  Behind  the  spine  of  the  ischium  the  pelvic  fascia  is  con- 
tinuous with  a  thin  layer  covering  the  pyriformis  muscle.  At  the 
"white  line"  the  pelvic  fascia  divides  into  the  recto-vesical  fascia, 
which  covers  the  upper  surface  of  the  levator  ani  muscles,  and  the 
obturator  fascia,  covering  the  obturator  muscles.  The  recto-vesical 
fascia  arising  from  the  ' '  white  line ' '  extends  downward  and  inward, 
and  unites  in  the  median  line  with  its  fellow  of  the  opposite  side. 
This  forms  a  fascial  diaphragm  which  is  perforated  by  the  rectum 
and  vagina,  to  each  of  which  it  is  firmly  attached  and  furnishes  a 
sheath  from  that  point  downward.  The  bladder  and  rectum  also 
receive  ligaments  from  this  fascia. 

On  removing  this  fascial  diaphragm,  we  meet  with  a  muscular 
diaphragm  formed  by  the  levator  ani  and  coccygeus  muscle  of  each 
side  meeting  in  the  median  line. 


40  ESSENTIALS  OF  GYNECOLOGY. 

The  coccygei  arise  from  the  ischial  spines,  and  are  attached  to  the 
sides  of  the  lower  segment  of  the  sacrum  and  to  the  sides  and  ante- 
rior surface  of  the  coccyx. 

The  levatores  ani  arise  from  the  posterior  aspect  of  the  pubes, 
from  the  spine  of  the  ischium  and  from  the  ' '  white  line  ' '  of  the 
pelvic  fascia  connecting  these  points.  They  extend  downward  and 
inward  and  are  attached  to  the  vagina,  the  rectum,  to  each  other 
and  to  the  tip  of  the  coccyx.  This  muscular  diaphragm  surrounds 
both  vagina  and  rectum. 

The  under  surface  of  this  muscular  diaphragm  is  covered  by  a  thin 
layer  of  fascia  which  is  attached  on  each  side  to  the  obturator  fascia. 
On  removing  the  muscular  diaphragm  with  its  upper  and  lower 
fascia,  there  remains,  filling  the  pelvic  outlet,  the  perineal  body,  the 
muscles  of  the  perineum  and  the  ischio-rectal  fossa. 


Perineal  Body. 

Describe. 

The  perineal  body  is  a  mass  of  muscular,  fibrous  and  adipose 
tissue,  somewhat  pyramidal  in  shape,  lying  between  the  lower  ends 
of  the  vagina  and  rectum  ;  it  measures  1$  inches  in  height,  1$ 
inches  in  breadth  and  |  inch  antero-posteriorly.  Its  base  is  covered 
by  skin  which  is  sometimes  wrongly  spoken  of  as  "the  perineum," 
which  should  always  refer  to  the  perineal  body. 

The  muscles  which  are  attached  to  the  perineal  body  are  the 
bulbo-cavernosi,  transversi  perinei,  sphincter  and  levatores  ani. 

Give  the  vascular  and  nerve  supply  of  the  perineal  body. 

The  arterial  supply  of  the  perineal  body  is  from  the  internal 
pudics. 

The  veins  terminate  in  the  pudic  veins. 

The  lymphatics  end  in  the  inguinal  glands. 

The  nerve  supply  is  from  the  pudic  nerve. 

What  are  the  functions  of  the  perineal  body  ? 

1.  To  prevent  vaginal  rectocele. 

2.  To  help  form  a  com  pact  pelvic  floor. 

3.  To  serve  as  a  fixed  point  for  muscular  attachment. 


ISCHIO-RECTAL  FOSSA.  41 

Muscles  of  the  Perineum. 

Name  and  describe  them. 

On  each  side  of  the  vaginal  orifice  we  find  three  muscles  :  bulbo- 
cavernosus,  ischio-cavernosus  or  erector  clitoridis,  and  the  trans- 
versa perinei. 

The  bulbo-cavernosus  arises  from  the  perineal  body  on  each  side 
of  the  vagina,  with  its  fellow  encircles  the  vaginal  bulbs  and  vesti- 
bule, and  divides  into  three  slips  ;  one  going  to  the  posterior  surface  of 
the  bulb,  another  to  the  under  surface  of  the  corpus  cavernosum  of 
the  clitoris,  and  the  third  to  the  mucous  membrane  of  the  vestibule. 

The  bulbo-cavernosi  compress  the  bulbs  of  the  vagina. 

The  transversus  perinei  arises  from  the  ramus  of  the  ischium  and 
is  lost  in  the  perineal  body. 

The  ischio-cavernosus  or  erector  clitoridis,  arises  from  the  front  of 
the  tuberosity  of  the  ischium  and  is  inserted  into  the  eras  clitoridis. 

These  muscles  are  supplied  by  the  internal  pudic  artery  and  by 
branches  of  the  pudic  nerve. 

The  veins  enter  the  pudic  veins. 

The  lymphatics  terminate  in  the  inguinal  glands. 

Ischio-rectal  Fossa. 

Give  its  gross  anatomy. 

It  is  a  pyramidal-shaped  area,  largely  filled  with  fat,  situated  on 
either  side  of  the  rectum ;  the  sides  are  formed  by  the  obturator 
internus  without  and  the  levator  ani  within  ;  the  base  by  the  trans- 
versus perinei  and  the  lower  edge  of  the  gluteus  maximus. 

Describe  the  fascia  covering  the  pelvic  floor  below. 

From  without  inward  we  find  the  superficial  fascia  in  two  layers, 
the  external  being  continuous  with  the  general  superficial  fascia  of 
the  body.  The  deep  layer  is  attached  to  the  border  of  the  pubic 
arch  in  front  and  laterally ;  posteriorly,  it  passes  around  the  trans- 
versus perinei  muscles  and  is  attached  to  the  base  of  the  anterior 
layer  of  the  triangular  ligament. 

Beneath  the  perineal  muscles  we  find  the  triangular  ligament,  con- 
sisting of  two  layers  of  fascia,  the  anterior  and  posterior,  filling  in 
the  pubic  arch. 


42  ESSENTIALS   OF  GYNAECOLOGY. 


Development  of  the  Pelvic  Organs. 

Describe  briefly. 

In  the  latter  part  of  the  first  month  there  appear  in  the  foetus, 
on  either  side  of  the  primitive  vertebrae,  the  Wolffian  bodies,  which 
play  the  part  of  temporary  kidneys.  They  soon  wither,  and  by  the 
end  of  the  3d  month  have  largely  disappeared,  but  their  remains  per- 
sist, in  the  female,  in  the  parovarium  and  Graertner'  s  duct.  At  the 
inner  side  of  the  Wolffian  bodies  there  appears  an  invagination  of 
ihe  germ  epithelium  ;  this  develops  into  the  duct  of  Mueller,  one 
for  each  Wolffian  body.  These  coalesce  below  to  form  the  uterus 
and  vagina. 

The  ovaiy  first  appears  as  a  white  ridge  on  the  inner  side  of  the 
Wolffian  body  ;  this  ridge  being  formed  of  connective  tissue  covered 
with  genu  epithelium  ;  from  the  former  is  developed  the  stroma  of 
the  ovary,  and  from  the  latter  are  formed  the  Graafian  follicles  and 
ova. 

Until  the  latter  part  of  the  second  month  of  foetal  life  the  urinary, 
genital  and  intestinal  canals  open  into  a  common  vault — the  cloaca. 
At  about  the  6th-7th  week  this  common  opening  is  divided  into  the 
anal  opening  posteriorly  and  the  uro-genital  anteriorly.  This  sepa- 
ration is  completed  by  the  formation  of  the  perineal  body  at  about 
the  tenth  week. 

The  uro-genital  canal  is  later  divided  into  the  urethra  anteriorly 
and  the  vagina  posteriorly. 


Physical  Examination  of  the  Female  Pelvic 

Organs. 

What  are  the  methods  of  examination? 
I.   Non-instrumental.     II.  Instrumental. 
I.   Non-instrumental. 

a.  Inspection  of  external  genitals  ;  only  when  especially  indicated. 

b.  External  abdominal  examination. 

c.  Vaginal  examination. 

d.  Bimanual  examination,  with  its  modifications. 

e.  Rectal  examination. 


VAGINAL  EXAMINATION.  43 

What  should  you  notice  on  inspection  of  the  external  gen- 
itals ? 

1 .  Notice  whether  or  not  the  vulva  is  the  seat  of  venereal  sores 
warts,  abscesses,  pediculi,  etc. 

2.  Separate  labia  and  notice  condition  of  hymen  and  perineum, 
whether  intact  or  lacerated  ;  the  shape  of  hymen  if  intact.  If  peri- 
neum lacerated,  notice  whether  through  the  sphincter  ani  or  not ; 
notice,  also,  condition  of  urethra. 

3.  Tell  patient  to  strain,  and  with  labia  still  separated,  notice 
whether  anterior  or  posterior  vaginal  walls  prolapse  or  not,  thus 
forming  cystocele  or  rectocele. 

What  are  the  principal  elements  in  a  complete  external  ab- 
dominal examination  ? 

1.  Position  and  Preparation  of  patient. — Patient  should  be  on 
back  with  knees  drawn  up  ;  the  abdomen  should  be  uncovered  as 
low  down  as  the  pubes  ;  the  latter  not  being  exposed  ;  bladder  and 
rectum  should  be  empty. 

2.  Inspection. — Observe  the  form  and  color;  notice  whether 
irregularities  in  form  are  present  or  not. 

3.  Palpation. — Use  both  hands  ;  they  should  be  warm  ;  use  the 
palms  and  palmar  surface  of  fingers  rather  than  their  tips  ;  employ 
very  little  force.  .  If  a  tumor  is  present,  notice  whether  it  is  solid  or 
fluctuating,  whether  fixed  or  mobile  ;  if  possible,  determine  whether 
or  not  it  is  attached  to  one  of  the  pelvic  organs. 

Notice  whether  it  pulsates  or  is  the  seat  of  intermittent  contrac- 
tions. 

Palpate  inguinal  regions  for  enlarged  glands  or  herniae. 

4.  Percussion. — Patient  should  be  first  percussed  in  usual  manner 
while  lying  on  back  and  then  when  turned  on  either  side. 

Vaginal  Examination. 

Describe  the  method  of  performing"  it. 

Have  the  patient  on  back  ;  knees  drawn  up  ;  if  a  married  woman, 
employ  two  fingers,  if  unmarried,  use  one. 

Have  the  examining  finger  or  fingers  well  lubricated  and  folded 
into  the  palm  until  you  approach  the  vulva  ;  then  let  them  sweep 
over  the  perineum  and  fourchette  between  the  labia  till  they  enter 


44  ESSENTIALS  OF  GYNECOLOGY. 

the  vaginal  orifice.  Do  not  pass  from  above  downward  over  the 
clitoris.  After  entering  the  vagina  pass  the  finger  or  fingers  back- 
ward toward  the  hollow  of  the  sacrum. 

What  are  the  contraindications  to  a  vaginal  examination  ? 

A  vaginal  examination  should  not  be  made  in  an  unmarried 
woman  unless  there  are  strong  reasons  for  suspecting  trouble  with 
the  pelvic  organs,  and  then  only  in  the  presence  of  a  relative  or 
female  friend. 

It  should  not  be  made  during  a  normal  menstruation. 

What  is  the  value  of  a  vaginal  examination  per  se  ? 

The  value  of  a  vaginal  examination  by  itself  is  comparatively 
small ;  and  it  is  rarely  employed  save  as  a  part  of  a  bimanual 
examination. 

One  can,  however,  determine  the  following  points  by  a  vaginal 
examination,  and  they  should  be  carefully  noted  : — 

The  condition  of  perineum  and  vaginal  orifice. 
Presence  or  absence  of  Painful  Spots  ; 
Spasm  ; 

Enlargement  of  vulvo-vaginal  glands  ;  etc. 
Condition  of  vaginal  walls  : — 

Heat; 

Moisture ; 
Presence  or  absence  of 

Rugae ; 

New  growths ; 

Fistulse ;  etc. 
Projections  of  vaginal  walls  from 

Faeces  in  rectum  ; 

Inflammatory  deposits ; 

Tumors  in  the  peritoneal  pouches* 


Condition  of  cervix  : — 


Position  ; 
Shape ; 
Size  ; 
Density ; 
Mobility ; 
Lacerated  or  not. 


BIMANUAL  EXAMINATION.  45 

Condition  of  os : — 

Size  ; 

Shape ; 

Projections  through  it. 

Bimanual  Examination. 

What  is  the  method  of  performing  it  ? 

The  position  of  the  patient  and  the  method  of  introducing  fingers 
are  the  same  as  for  the  vaginal  examination  just  described.  As 
regards  which  hand  shall  be  used  internally,  the  right  is  usually 
employed  first ;  but  to  make  a  complete  bimanual,  it  is  best  to 
employ  internally  the  right  hand  for  the  right  side  of  the  pelvis, 
and  the  left  hand  for  the  left ;  in  this  way  the  palmar  surfaces  of 
the  internal  and  external  fingers  are  approximated,  and  any  depart- 
ure from  the  normal,  on  either  side,  is  better  mapped  out  than 
when  the  right  hand  alone  is  used  for  the  internal  examination. 

Describe  the  use  of  the  external  hand  in  the  bimanual. 

The  ulnar  surface  of  the  external  hand  should  be  used  rather  than 
the  palm  ;  it  should  be  applied  to  the  abdomen  a  little  above  the 
pubes  and  steadily  depressed  toward  the  opposing  fingers  within  the 
vagina,  while  the  patient  relaxes  her  abdominal  muscles  and  breathes 
quietly,  with  mouth  open. 

Describe  the  use  of  the  internal  examining  fingers  in  the 
bimanual. 

While  the  ring  and  little  fingers  are  strongly  flexed  into  the  palm 
and  the  thumb  lies  on  the  pubes  or  between  the  thighs,  place  the 
middle  examining  finger  on  the  cervix  and  the  index  in  the  anterior 
fornix  and  raise  the  uterus  toward  the  external  hand.  The  first 
step  for  the  student  in  acquiring  skill  in  the  bimanual  is  to  feel, 
through  the  abdominal  wall,  a  body  which  transmits  motion  from 
the  external  hand  to  the  finger  on  the  cervix.  This,  in  a  normal 
case,  is  the  fundus  of  the  uterus  ;  future  examinations  will  enable 
one  to  map  out  more  and  more  the  shape  of  the  fundus. 

What  is  a  good  order  to  follow  in  making  a  bimanual  exam- 
ination ? 
1.  Determine  the  position  of  the  uterus  by  attempting  to  approxi- 


46  ESSENTIALS   OF  GYNAECOLOGY. 

mate  external  and  internal  fingers  ;  the'  internal  being  placed  first  on 
cervix,  then  in  anterior  fornix  and  then  in  posterior ;  the  external 
hand  exerting  counter  pressure. 

2.  Determine  condition  of  tubes,  ovaries  and  parametria ;  using 
right  hand  internally  for  right  side  of  the  pelvis  and  left  for  left. 

Should  you  normally  feel  a  hard  body  in  any  of  the  four  for- 
nices  of  the  vagina  ?  If  so,  which  one,  and  what  is  it  1 
Yes,  in  the  anterior  fornix  ;  the  body  of  the  uterus. 

Should  you  normally  feel  a  hard  body  in  the  posterior  or 
either  of  the  lateral  fornices  ? 

No. 

What  mass  might  you  feel  in  the  anterior  fornix  ? 

1 .  A  fibroid  on  anterior  wall  of  the  uterus. 

2.  Inflammatory  or  blood  effusions,  rarely. 

What  mass  might  you  feel  in  either  of  the  lateral  fornices  ? 

Inflammatory  deposit  from  cellulitis  or  peritonitis. 
Blood  effusion. 
Enlarged  tube  or  ovary. 
Body  of  uterus  latero-flexed. 
Lateral  fibroid. 

What  mass  might  you  feel  in  posterior  fornix  ? 

Displaced  fundus. 

Faeces  in  rectum. 

Fibroid  on  wall  of  uterus. 

Peritonitic  or  cellulitic  deposit. 

Hgernatocele. 

Displaced  ovary. 

Tumor. 

Rectal  Examination. 

What  are  the  methods  ? 

1.  Simple  rectal. 

2.  Abdomino-rectaL 
:;.  Simon's  method. 

What  are  the  preliminaries  to  any  rectal  examination  ? 
I  [ave  bowels  empty. 
Tell  patient  what  you  are  to  do, 


RECTAL  EXAMINATION.  47 

Have  soap  under  finger-nail. 
Lubricate  finger. 

How  would  you  perform  the  simple  rectal  examination  ? 

Having  observed  the  preceding  preliminaries,  pass  the  finger  for- 
ward, noting  the  presence  or  absence  of  hemorrhoids,  fissures,  polypi, 
stricture,  etc. ,  till  the  cervix  is  felt,  then  pass  along  posterior  wall 
of  the  uterus. 

How  would  you  perform  the  abdomino-rectal  examination  ? 

Passing  the  right  index  finger  into  the  rectum  as  just  described, 
use  the  left  hand  externally,  placed  on  the  abdomen  as  in  the  ordi- 
nary bimanual. 

What  is  Simon's  method? 

This  consists  in  passing  the  whole  hand,  shaped  like  a  cone, 
gradually  through  the  anus  into  the  rectum. 

What  is  the  value  of  the  different  methods  of  rectal  exami- 
nation ? 

Both  the  simple  rectal  and  abdomino-rectal  are  of  especial  value 
in  virgins,  where  the  .ordinary  bimanual  is  painful  or  objected  to. 

By  means  of  a  volsella  forceps  you  may  draw  down  the  cervix,  and 
then,  with  finger  in  the  rectum,  palpate  the  posterior .  surface  of 
uterus,  tubes  and  ovaries. 

The  above  methods  of  rectal  examination  are  of  value  in  any  case 
where  you  wish  to  reach  higher  than  is  possible  with  the  ordinary 
bimanual. 

Advantage  is  sometimes  gained  by  making  the  rectal  examination 
with  patient  in  Sims'  position. 

Simon's  method  is  dangerous  and  seldom  justifiable. 


48 


ESSENTIALS   OF  GYNECOLOGY. 


INSTRUMENTS. 
Specula. 

What  are  the  three  classes  of  specula  in  most  common  use  ? 

1.  The  Spatular. 

2.  The  Cylindrical. 

3.  The  Bivalve. 

Give  one  of  the  best  examples  of  the  spatular  variety ; 
describe  it. 

The  Sims  speculum  (see  Fig.  5)  is  the  best  example  of  this  class ; 
it  consists  of  two  blades  united  by  a  handle  at  right  angles  to  them, 

Fig.  5. 


Sims'  Speculum. 


the  blades  being  convex  on  the  sides  facing  each  other,  concave  on 
the  opposite.  Many  modifications  are  made  by  which  the  length  of 
blade,  angle  at  which  it  joins  the  shaft,  and  weight  of  the  whole 
instrument  are  altered.  One  blade  of  the  Sims  speculum  is  usually 
made  shorter  and  smaller  than  the  other. 

What  are  the  advantages  of  Sims'  speculum  ? 

It  does  not  distort  cervix. 

It  gives  a  good  view  of  all  but  the  posterior  vaginal  wall,  and  is 
the  best  suited  for  operations  on  <-<Tvix  and  anterior  vaginal  wall. 


INSTRUMENTS — SPECULA. 


49 


What  are  the  disadvantages  of  Sims'  speculum  ? 

It  requires  an  assistant  with  some  training  to  hold  it. 

It  requires,  in  most  cases,  the  use  of  a  vaginal  depressor,  thus 
employing  one  hand. 

What  is  the  proper  position  of  the  patient  for  the  use  of  Sims' 
speculum  ? 

A  patient  in  the  so-called  ' '  Sims  position  ' '  should  lie  on  her  left 
side,  with  left  buttock  on  the  left  corner  of  the  table,  as  you  face  it ; 
the  head  being  at  the  right  corner  of  the  head  of  the  table,  the  left 
arm  behind  the  patient ;  the  right  arm  should  lie  over  the  right 
edge  of  the  table,  the  right  shoulder  being  kept  as  near  the  table  as 


Fig.  6. 


possible, 
the  left. 


The  knees  should  be  drawn  up,  the  right  a  little  above 


How  would  you  introduce  a  Sims  speculum  ? 

Having  placed  the  patient  in  the  correct  Sims  position,  select  the 
blade  you  are  to  use ;  warm  and  lubricate  the  convex  side  of  it ; ' 
take  the  speculum  in  the  right  hand  with  the  index  finger  lying  in 
the  concavity  of  the  blade,  and  introduce  finger  and  blade  together. 
The  breadth  of  the  blade  should  be  in  line  with  the  labia  until  it 
has  entered  the  vaginal  orifice  ;  it  should  then  be  rotated  till  the 
convexity  lies  in  apposition  with  the  posterior  vaginal  wall,  which  it 
should  hug  closely  till  the  posterior  fornix  is  reached  and  the  index 
finger  detects  the  cervix  in  front  of  it ;  the  speculum  is  then  given 
to  an  assistant  to  hold.  Some  introduce  the  finger  first  and  pass 
the  blade  along  it. 

4  _ 


50  ESSENTIALS   OF  GYNAECOLOGY. 

How  would  you  hold  a  Sims  speculum  ? 
There  are  two  methods  in  common  rise  : — 

(a)  One  is  to  grasp  the  outside  blade  with  the  right  hand,  the 
angle  between  blade  and  handle  fitting  over  index  finger,  as  seen  in 
Fig.  6  ;  the  thumb  lying  in  the  concavity  of  the  blade  over  the 
angle. 

The  right  buttock  should  be  raised  with  the  left  hand. 

(b)  The  other  method  is  to  grasp  the  handle  of  the  speculum  with 
the  right  hand,  having  the  convexity  of  the  outside  blade  rest  in 
the  hollow  between  the  thumb  and  index  finger. 

The  right  buttock  being  raised  as  in  the  other  method. 


Fig.  7. 


Fergusson's  Speculum. 

What  is  one  of  the  best  examples  of  a  cylindrical  speculum  ? 
Describe  it. 

The  cylindrical  speculum  of  Fergusson  (see  Fig.  7)  is  probably  the 
best  of  its  class  ;  it  is  a  cylinder  of  glass  or  hard  rubber,  with  one 
extremity  beveled  and  the  other  trumpet-shaped. 

The  glass  ones  usually  present  a  mirrored  surface  from  within. 

The  beveled  extremity  is  the  one  first  introduced. 

What  are  the  merits  of  the  Fergusson  speculum  ? 

It  is  of  very  limited  use  ;  it  may  be  employed  for  inspecting  the 
cervix  or  making  applications  to  it.  It  is  useless  for  operations,  on 
the  cervix  ;  it  is  only  partially  self-retaining,  and  its  introduction  in 
nulliparae  is  painful. 

How  would  you  introduce  a  Fergusson  speculum  ? 

In  this  country  the  Fergusson  speculum  is  usually  employed  with 
tli<    patient  >"  tlig  dorsal  position. 


INSTRUMENTS — SPECULA. 


51 


Separate  the  labia  with  the  fingers  of  the  left  hand  ;  holding  the 
trainpet-shaped  extremity  with  the  right  hand,  introduce  the 
beveled  extremity  into  the  vaginal  orifice  having  the  shorter  side 
anterior  ;  depress  well  the  perineum,  directing  the  speculum  toward 
the  hollow  of  the  sacrum  ;  by  slight  vertical,  horizontal  or  rotatory 
motion  of  the  speculum  while  looking  into  it,  the  cervix  is  now 
usually  brought  into  view  without  difficulty.  It  is  occasionally 
convenient  to  draw  the  cervix  more  fully  into  view  by  means  of  a 
tenaculum. 

Some  gynaecologists  use  the  Fergusson  speculum  with  the  patient 
in  Sims'  position. 


Fig.  8. 


A.^ 


Brewer's  Speculum. 


What  is  one  of  the  best  examples  of  a  bivalve  speculum  ? 
Describe  it. 

The  Brewer  bivalve  (see  Fig.  8)  is  probably  the  best  speculum 
of  its  class ;  it  consists  of  two  blades,  the  outer  extremities  being 
trumpet-shaped  where  they  are  jointed  ;  the  anterior  blade  is  shorter 
than  the  posterior,  and  has  a  slot  in  its  outer  half,  to  avoid  pressure 
on  the  urethra  ;  this  also  facilitates  the  introduction  of  the  sound  or 
probe.  The  speculum  is  opened  by  approximating  the  handles  of 
the  blades  and  held  there  by  a  thumb-screw.  There  are  two  sizes 
of  Brewer's  speculum,  the  long  and  short, 


52 


ESSENTIALS   OF  GYNAECOLOGY. 


How  would  you  introduce  a  Brewer  speculum  ? 

Place  patient  in  dorsal  position  ;  pass  speculum  into  vaginal  orifice 
with  the  blades  lateral,  then  rotate  till  they  are  antero-posterior ; 
begin  to  open  blades  just  before  they  reach  the  cervix  ;  when  com- 
pletely open,  hold  with  thumb-screw. 

What  are  the  merits  of  Brewer's  speculum  ? 

For  inspection  of,  and  applications  to,  the  cervix,  it  is  very  valu- 
able ;  it  is  self-retaining,  thus  obviating  the  necessity  of  an  assistant. 

The  long  instrument  is  better  than  the  short,  as  with  it  the 
vaginal  walls  are  not  as  likely  to  obstruct  the  view  by  falling  in  be- 
yond the  blades,  and  at  the  same  time  it  accomplishes  all  that  the 
short  instrument  does. 

fig.  9.  What  are  the  disadvantages  of  Brewer's 

speculum  ? 
It  distorts  the  cervix,  obscures  the  anterior 
vaginal  wall,  and  cannot  be  used  for  operations 
on  the  cervix  or  vagina. 

Volsella. 

Describe  it. 

The  Volsella,  or  vulsellum  forceps  (see  Fig.  9) 
consists  of  a  pair  of  hooks  with  scissor  handles 
and  joint ;  the  hooks  usually  consist  of  two  or 
more  teeth  ;  the  handles  fasten  with  a  catch. 

What  are  the  uses  of  the  Volsella  ? 

In  all  operations  on  the  cervix,  trachelor- 
rhaphy, dilatation,  etc. ,  the  volsella,  or  one  of 
its  substitutes,  is  almost  indispensable,  to  draw 
down  and  hold  the  cervix. 

For  applications  to,  or  operations  on,  the 
interior  of  the  body  of  the  uterus,  the  volsella 
is  also  of  great  value. 

The  use  of  the  volsella  to  draw  down  the 
cervix,  in  connection  with  the  finger  in  the  rectum,  in  the  combined 
rectal  examination,  is  of  great  importance. 

How  would  you  introduce  and  apply  the  Volsella? 

The  position  for  most  operations  on  the  cervix  is  the  Sims  position, 


The  Vulsella. 


INSTRUMENTS — UTERINE  SOUND.  53 

consequently  the  volsella  is  most  often  used  in  this  position.  It  may 
be  introduced  either  without  or  with  the  use  of  the  speculum  ;  if 
without  the  speculum,  the  first  two  fingers  of  the  right  hand  are 
introduced  till  the  anterior  lip  of  the  cervix  is  felt ;  the  volsella  is 
then  passed  along  them  and  applied  to  the  anterior  lip,  which  is 
then  drawn  down. 

The  better  way  is  usually  to  employ  Sims'  speculum  and  apply  the 
volsella  directly  to  the  anterior  lip  by  sight. 

The  volsella  is  occasionally  employed  with  patient  in  the  dorsal 
position,  the  instrument  being  introduced  either  by  touch,  or  sight 
aided  by  a  speculum. 

What  could  you  substitute  for  a  Volsella  ? 

The  U.  S.  bullet  forceps,  having  only  one  pair  of  teeth,  may 
often  be  substituted  for  a  volsella. 

A  tenaculum,  such  as  Sims',  which  is  a  sharp  hook  on  a  long 
slender  shank,  is  often  of  great  use  in  holding  the  cervix  and  draw- 
ing it  in  any  direction,  and  can  sometimes  be  substituted  for  a  vol- 
sella. 

Uterine  Sound. 

What  are  the  two  sounds  in  most  general  use  ?  their  descrip* 
tion  and  merits  ? 
The  Sir  J.  Y.  Simpson's  sound  and  that  of  A.  R  Simpson  are 
the  two  in  most  general  use. 

Fig.  10. 


Sir  J.  Y.  Simpson's  Sound. 

They  are  both  rods  of  copper,  nickel-plated,  and  so  pliable  that 
they  can  easily  be  bent  with  the  fingers. 

The  sound  of  Sir  J.  Y.  Simpson  (see  Fig.  10)  is  12  inches  long, 
with  a  notched  knob  21  inches  from  the  end,  and  notches  at  3£,  4?, 
etc.,  up  to  8 J  inches, 


54 


ESSENTIALS   OF   GYNECOLOGY. 


The  handle  is  roughened  on  the  side  of  the  concavity  of  the 
curve. 

The  sound  of  A.  R.  Simpson  (see  Fig.  11)  is  only  9  inches  long  ; 
it  has  a  prominent  ring  at  2\  inches  and  two  rings  at  4J  inches ; 
there  are  also  markings  at  3J  and  5i  inches.  This  sound  has  an 
advantage  over  the  preceding  in  that,  being  only  9  inches  long,  the 
handle,  which  is  broad,  can  rest  firmly  on  the  ball  of  the  little  finger 
even  when  the  tip  of  the  index  finger  is  on  the  1\  inch  ring,  thus 
giving  one  a  complete  control  of  the  instrument  when  the  finger  is 
in  the  vagina  with  the  sound.     This  is  impossible  with  the  sound  of 

Fig.  11. 


A.  R.  Simpson's  Sound.    {Hart  and  Barbour.) 


Sir  J.  Y.  Simpson,  as  in  similar  circumstances  the  handle  is  far 
above  the  hand,  and  one  can  only  grasp  the  shank,  which  readily 
rotates.  The  presence  of  the  double  ring  is  also  an  advantage  in  an 
enlarged  uterus. 

What  are  the  contraindications  to  the  use  of  the  sound  ? 

Patient  has  skipped  a  menstrual  period. 

Menstruation  present. 

Acute  inflammation  present  in  uterus  or  neighborhood. 

Malignant  disease  of  uterus. 

What  are  the  preliminaries  to  the  use  of  the  sound  ? 

1.  Be  sure  that  the  patient  has  not  skipped  a  menstrual  period. 

2.  Determine  position  of  uterus  by  a  careful  examination. 


INSTRUMENTS — UTERINE  SOUND.  55 

3.  Curve  sound  to  the  curve  of  the  uterus. 

4.  Cleanse  the  vagina  with  an  antiseptic  solution.  This  is  of  im- 
portance to  avoid  carrying  septic  material  froni  vagina  to  uterus  by 
the  sound.  For  this  reason  it  is  often  wiser  to  introduce  the  sound 
with  the  aid  of  a  speculum  which  separates  the  vaginal  walls  atid 
enables  you  to  reach  the  os  directly. 

5.  Position  of  the  patient : — 

This  is  largely  a  matter  of  choice,  but  in  this  country  the  dorsal 
position  is  usually  selected,  and  it  has  the  advantage  that  in  this 
position  the  bimanual  may  be  easily  combined  with  the  use  of  the 
sound. 

How  would  you  introduce  the  sound  with  patient  in  the  dor- 
sal position  ? 

Having  observed  the  preliminaries  just  mentioned,  introduce  the 
index  finger  of  the  left  hand  until  it  reaches  the  anterior  lip  of  the 
cervix,  then  along  the  finger  as  a  guide,  pass  the  sound  with  the 
concavity  backward  until  it  thoroughly  engages  in  the  cervix ;  then, 
if  the  fundus  lies  forward,  turn  the  sound,  not  by  rotating  the  shank, 
but  by  making  the  handle  describe  a  semicircle  from  behind,  to  the 
left  and  forward;  the  point  of  the  instrument  remaining  nearly 
stationary.  By  depressing  the  handle  toward  the  perineum,  the 
sound  will  then  usually  pass  without  trouble.  If  the  point  catches 
in  the  crypts  of  the  cervix,  slight  motion  will  usually  disengage  it. 

What  variation  in  this  procedure  would  you  make  if  the 
fundus  lay  posteriorly  ? 

Having  introduced  the  sound  into  the  cervix  as  before,  with  con- 
cavity backward,  continue  the  introduction  without  the  semicircular 
motion  of  the  handle. 

When  the  fundus  lies  forward,  the  sound  is  often  introduced  by 
placing  the  left  index-finger  on  the  posterior  lip  of  the  cervix  and 
then  passing  the  sound  along  this  with  concavity  forward,  continuing 
the  introduction  into  the  uterus  without  reversing  the  curve. 

If  the  fundus  lies  backward,  this  method  necessitates  the  semicir- 
cular motion  of  the  handle  in  the  opposite  direction — from  before, 
to  the  left,  backward. 


56  ESSENTIALS  OF  GYNECOLOGY. 

How  would  you  pass  the  sound  in  a  marked  case  of  ante- 
flexion ? 

If  the  uterus  is  anteflexed,  the  introduction  of  the  sound  is  facili- 
tated by  curving  the  sound  sharply,  drawing  down  the  cervix  with  a 
volsella  and  pushing  up  the  fundus  with  the  finger  in  the  anterior 

fornix. 

How  would  you  introduce  the  sound  with  patient  in  Sims' 
position  ? 

Having  observed  the  preliminaries,  introduce  right  index-finger 
till  it  touches  anterior  lip  of  the  cervix  ;  pass  sound,  held  in  left 
hand,  along  it  with  concavity  backward  till  it  engages  well  in  the 
cervical  canal,  then  make  handle  describe  a  semicircle  from  the  peri- 
neum upward  past  the  right  buttock,  down  toward  pubes,  then  con- 
tinue the  introduction. 

If  the  uterus  lies  posterior,  the  semicircular  motion  of  the  handle- 
is  unnecessary. 

When  uterus  lies  to  the  front,  the  sound  is  sometimes  introduced 
by  passing  the  first  two  fingers  of  left  hand  till  they  touch  the  pos- 
terior lip  of  the  cervix,  and  then  introducing  sound  directly  with  the 
concavity  forward. 

What  are  the  uses  of  the  uterine  sound  ? 

(a)  To  determine — 1.  The  length  of  uterine  canal. 

2.  Its  permeability. 

3.  Its  direction. 

4.  Condition  of  endometrium. 

5.  Growths  in  uterus. 

6.  Relation  of  uterus  to  tumors. 

(b)  To  replace  a  displaced  uterus. 

The  mobility  of  the  uterus  and  the  relation  of  cervix  and  body 
should  be  determined  by  the  bimanual,  not  by  the  sound. 

What  are  the  dangers  in  the  use  of  the  sound  ? 

1.  Pelvic  peritonitis  or  cellulitis,  from  introduction  of  sepsis. 

2.  Abortion. 

3.  Hemorrhage,  especially  in  malignant  disease. 

4.  Perforation  of  uterine  walls. 


INSTRUMENTS — TENTS.  57 

Uterine  Probe. 

Give  its  description  and  uses. 

The  uterine  probe  is  usually  a  slimmer  instrument  than  the  sound, 
made  of  silver,  hard  rubber  or  whalebone,  with  end  slightly  bulbous. 
Except  in  cases  of  stenosis,  it  is  harder  to  introduce  than  the  sound, 
and  of  less  general  value.  It  should  be  introduced  by  sight,  while 
cervix  is  steadied  with  a  tenaculum . 

Dilators. 

What  are  the  methods  of  dilating  the  cervical  canal  ? 

1.  By  tents. 

2.  By  graduated  hard  dilators. 

3.  By  dilators  of  the  glove-stretcher  variety. 

4.  By  elastic  dilators — Barnes'  bag  or  Allen's  pump. 

Tents. 

What  do  yon  mean  by  a  tent  as  employed  in  gynaecology  ? 
Give  the  varieties  in  use. 

A  tent  is  a  cone  of  some  expansile  material,  which,  by  absorption 
of  moisture,  expands  after  introduction  into  the  cervix  sufficiently, 
both  in  extent  and  force,  to  dilate  the  canal. 

There  are  several  varieties  of  tents  in  use,  named  according  to 
their  material. 

1.  Sponge. 

2.  Sea-tangle  (Laminaria  digitata). 

3.  Tupelo  (Nyssa  aquatilis). 

4.  Cornstalk. 

What  are  the  merits  of  each  ? 

The  sponge  tent  expands  easily,  but  it  is  the  most  dangerous  of 
all,  from  the  fact  that  it  absorbs  so  readily  material  which  easily 
becomes  septic. 

The  sea-tangle  tent  is  less  dangerous  than  the  preceding,  and 
dilates  well,  but  it  expands  unevenly,  and  its  edges  are  rough  after 
expansion. 


58  ESSENTIALS   OF  GYNECOLOGY. 

The  tupelo  tent  is  the  best  of  all.  It  expands  evenly  and  smoothly, 
and  is  the  least  liable  to  cause  sepsis. 

The  cornstalk  is  feeble  in  action  and  seldom  used. 

What  are  the  indications  for  the  use  of  tents  ? 

1.  To  dilate  the  cervical  canal  for  purposes  of  diagnosis  or  opera- 
tion. 

2    To  check  hemorrhage. 

What  are  the  merits  of  tents  for  these  uses  ? 

The  employment- of  tents  has  greatly,  and  very  wisely,  diminished 
of  late.  For  diagnostic  purposes  they  are  still  occasionally  employed 
to  dilate  the  cervical  canal,  so  that  the  finger  can  be  introduced,  but 
they  are  dangerous,  slow  and  painful,  and  we  have,  in  most  cases, 
better  means,  in  dilators  of  the  glove-stretcher  variety  or  Allen's 
pump,  for  accomplishing  the  same  result. 

The  use  of  tents  to  check  hemorrhage  was  chiefly  in  abortion  ;  the 
dilatation  of  the  canal  being  sought  for  at  the  same  time.  We  now 
have  better  means  in  the  elastic  dilators. 

What  are  the  preliminaries  to  the  use  of  tents  ? 

All  antiseptic  precautions  should  be  observed.  Patient  should 
have  an  antiseptic  vaginal  douche. 

You  should  determine  accurately  the  position  of  the  uterus. 

Tents  should  be  curved  to  the  direction  of  the  canal. 

A  string  should  be  passed  through  the  tent,  for  ease  in  with- 
drawal. 

Patient  should  be  in  Sims'  position. 

How  would  you  introduce  a  tent  ? 

1 .  Introduce  Sims'  speculum  ;  draw  down  cervix  with  volsella, 
then  taking  the  tent  in  a  pair  of  dressing  forceps  or  on  a  tent  car- 
rier, pass  it  into  cervical  canal  by  sight ;  insert  a  tampon  and  give 
an  opium  suppository. 

What  should  be  the  future  treatment  of  the  case  ? 

Tents  should  not  be  left  in  over  6-12  hours ;  sponge  tents  not 
over  6  hours.     In  removing  a  tent,  do  not  rotate  it. 

Patient  must  remain  in  bed  for  24  hours,  and  not  leave  the  house 
for  3-4  days. 


INSTRUMENTS — GRADUATED   HARD   DILATORS.  £9 

Graduated  Hard  Dilators. 

Describe  them. 

There  are  several  varieties  in  common  use,  among  which  are  Peas- 
lee's,  Kammerer's,  Hank's,  etc. 

The  first  two  resemble  male  sounds,  except  that  the  curve  is  less 
acute,  and  at  2h  inches  there  is  a  bulb. 

Hank's  dilator  has  a  more  olive-shaped  extremity  of  various  sizes. 

Ordinary  male  sounds,  Nos.  15  to  18,  French,  may  often  be  sub- 
stituted for  the  dilators  just  mentioned. 

What  are  indications  for  the  use  of  graduated  hard  dilators  ? 

1.  By  themselves  to  dilate  a  stenosis  of  the  cervix  causing  dys- 
nienorrhcea  or  sterility.  Under  stenosis  here  is  included  that  caused 
by  flexions. 

2.  To  maintain  a  dilatation  produced  by  one  of  the  more  power- 
ful dilators. 

Describe  the  mode  of  employment  of  these  graduated  hard 
dilators. 

Give  patient  an  antiseptic  douche ;  place  her  in  Sims'  position ; 
introduce  Sims'  speculum  ;  draw  down  and  hold  cervix  with  a  tenacu- 
lum or  volsella  ;  introduce  dilator  by  sight,  as  you  would  the  uter- 
ine sound,  beginning  with  the  smallest  size  and  increasing  to  the 
largest.  Cleanse  the  vagina  with  an  antiseptic  solution  (bichloride 
1-5000),  insufflate  iodoform  against  the  cervix  and  insert  an  iodo- 
form gauze  tampon  ;  keep  patient  in  bed  12-24  hours. 

Occasionally,  the  curve  of  the  uterus  is  such  that  it  is  easier  to 
introduce  the  dilators  with  patient  in  the  dorsal  position  and  with 
the  aid  of  the  bivalve  speculum. 

In  employing  these  graduated  dilators  for  stenosis  of  cervix 
causing  obstructive  dysmenorrhcea,  how  often  should 
they  be  introduced  ? 

It  is  usually  necessary  to  introduce  them  once  a  week  during  the 
first  month,  and  once  or  twice  a  month  for  a  few  months  afterward  ; 
exercising  each  time  the  same  antiseptic  precautions. 

Describe  the  dilators  of  the  glove-stretcher  variety. 

The  two  chief  styles  of  these  are  the  Sims  and  Ellinger's  ;  in  the 


60  ESSENTIALS  OF  GYNECOLOGY. 

latter  of  which  the  blades  are  caused  to  move  parallel,  and  on  the 
handle  there  is  a  graduated  scale.  There  are  numerous  modifica- 
tions of  these  dilators,  among  which  may  be  mentioned  Wylie's  and 
Goodell's. 

What  are  the  indications  for  the  employment  of  these  dila- 
tors? 

The  same  indications  obtain  as  for  the  preceding,  and  in  addition 
where  a  more  complete  dilatation  of  the  cervix  is  desired. 

The  first  and  more  complete  dilatation  is  often  performed  with  a 
dilator  of  this  class,  and  then  the  dilatation  maintained  by  the 
graduated  hard  dilators. 

What  are  the  preliminaries  to  the  use  of  the  glove-stretcher 
dilators  ? 

The  patient  should  have  an  antiseptic  douche,  and  for  complete 
dilatation,  anaesthesia. 

Describe  the  method  of  employing  these  dilators. 

The  patient  is  usually  placed  in  Sims'  position ;  insert  Sims" 
speculum  ;  draw  down  cervix  and  introduce  dilator  to  the  shoulder ; 
separate  blades  gradually  to  the  desired  extent,  being  careful  that 
the  instrument  does  not  slip  suddenly  and  lacerate  the  cervix.  The 
dilatation  is  sometimes  also  performed  with  patient  in  the  dorsal 
position. 

To  what  extent  should  you  carry  the  dilatation  ? 
Usually  from  J  to  1  inch. 


ELASTIC  DILATORS — THE  CURETTE.  61 


ELASTIC  DILATORS. 
Barnes*  Bags,  Allen's  Pump. 

Describe  them  and  the  method  of  using1  them. 

They  consist  of  India-rubber  bags,  of  different  sizes,  the  former 
being  fiddle-shaped,  the  latter  more  elongated.  They  are  intro- 
duced under  strict  antiseptic  precautions,  in  a  collapsed  condition, 
and  are  then  slowly  distended  with  air  or  water,  usually  the  former  ; 
the  Barnes'  bags  by  means  of  a  Davidson's  syringe,  Allen's  by  the 
pump. 

What  are  the  advantages  of  these  elastic  dilators  ? 

Their  method  more  closely  resembles  the  physiological  method  of 
dilating  the  cervix ;  the  dilatation  can  be  made  extensive  ;  the 
danger  of  laceration  of  the  cervix  is  slight. 

With  Allen's  pump  the  dilatation  can  be  made  comparatively 
rapid. 

What  are  the  dangers  of  mechanical  dilatation  % 

Laceration  of  the  cervix. 
Endometritis. 
Salpingitis. 
Peritonitis. 

The  Curette. 

Describe  it. 

The  curette  consists  usually  of  a  loop  of  wire,  either  blunt  or 
sharp,  on  a  rather  long  shank,  used  for  scraping  irregularities  or  new 
growths  from  the  endometrium. 

Occasionally,  it  is  made  like  a  small  cup,  with  a  sharp  edge,  at- 
tached to  a  long  shank.     Simon's  spoon  is  of  this  description. 

What  are  the  varieties  in  common  use  ? 

Thomas'  wire  loop,  dull  and  flexible. 
Sims'  curette. 
Recamier  curette. 
Simon's  spoon. 


02  ESSENTIALS   OF  GYNECOLOGY. 

What  is  the  value  of  the  curette  ? 

It  is  a  very  valuable  instrument,  both  for  diagnosis  and  treatment. 

a.  For  diagnosis,  to  scrape  away  some  of  the  contents  of  the 
uterus,  for  examination,  to  determine  the  cause  of  hemorrhage. 

b.  For  treatment,  to  scrape  away  villous  growths,  which,  by  their 
vascularity,  easily  cause  hemorrhage. 

In  malignant  disease  of  the  uterus,  the  curette  is  also  of  value  to 
remove  sloughing  masses. 

What  are  the  preliminaries  to  the  use  of  the  curette  ? 

The  patient  should  have  an  antiseptic  douche,  and  all  antiseptic 
precautions  should  be  observed  in  regard  to  instruments,  hands,  etc. 

She  should  be  placed  in  Sims'  position ;  Sims'  speculum  intro- 
duced ;  cervix  drawn  down  and  steadied  by  a  tenaculum  ;  the  cervix, 
if  necessary,  should  be  dilated. 

If  the  sharp  curette  is  to  be  used,  it  is  better  to  use  anaesthesia ;  if 
only  the  blunt  curette  is  to  be  employed,  anaesthesia  is  unnecessary. 

Describe  briefly  the  method  of  curetting. 

If  the  operation  is  to  be  curative,  scrape  the  interior  of  the  uterus 
carefully  till  the  walls  feel  smooth  ;  then  wash  out  uterus  with  an 
antiseptic  solution,  with  the  aid  of  a  double  current  catheter  ;  dry 
the  vagina,  then  touch  the  interior  of  the  uterus  with  carbolic  acid 
or  the  so-called  iodized  phenol,  consisting  of  iodine,  gr.  xl,  carbolic 
acid  ^j.     Confine  patient  to  bed  12-24  hours. 

What  are  the  dangers  of  the  curette  ? 

Inflammation  of  the  uterus  or  its  adnexa. 

Peritonitis. 

Hemorrhage. 

Septicaemia. 

Vulvitis. 

What  are  the  varieties  ? 

1.  Simple  catarrhal,  acute  or  chronic 

2.  Gronorrhoeal ; 

3.  Phlegmonous  ; 

4.  Diphtheritic; 

5.  Gangrenous ; 
b.  Occurring  in  adults  :  Follicular, 


a.  Occurring    in  both 
children  and  adults  : 


VULVITIS.  63 

I.  Acute  Simple  Catarrhal  Vulvitis, 

What  are  the  causes  ? 

Lack  of  cleanliness  ; 

Strumous  diathesis  ; 

Discharges  from  cervix,  or  vagina  ; 

Injuries  or  friction  from  exercise  ; 

Masturbation  ; 

Awkward,  or  excessive  coitus  ; 

Pregnancy ; 

Foreign  bodies  ; 

Parasites ; 

Acute  exanthemata. 

What  are  the  symptoms  ? 

General  malaise  ;  some  local  pain  and  burning  ;  parts  are  oedema- 
tous,  congested,  covered  with  a  glairy,  mucous,  excoriating  discharge, 
which  may  extend  to  the  urethra. 

What  is  the  treatment  ? 

Rest  in  bed  ;  warm  sitz-baths ;  lead  and  opium  wash  frequently 
applied  to  the  vulva  ;  lint  soaked  in  it  kept  between  the  labia.  Bis- 
muth, starch,  or  borax  may  with  advantage  be  dusted  on  the  vulva 
in  the  intervals  between  the  applications  of  the  lead  and  opium 
wash.  If  the  vulvitis  is  from  ascarides,  employ  enemata  of  infusion 
of  quassia,  §  ij-Oj. 

Chronic  Catarrhal  Vulvitis. 

Describe  its  occurrence  and  course. 

Catarrhal  vulvitis  in  children  is  most  apt  to  be  chronic  ;  it  is  seen 
most  frequently  in  strumous  children,  often  with  no  history  of  the 
acute  stage. 

What  are  the  symptoms  ? 

1.  Discomfort  in  walking  and  in  micturition  ; 

2.  Pruritus ; 

3.  Stains  on  linen. 

What  is  the  treatment  ? 

Build  up  the  constitution  by  tonics  and  fresh  air  ;  observe  cleanli- 
ness ;  if  much  discomfort,  use  lead  and  opium  wash,  followed  later 


64  ESSENTIALS   OF  GYNAECOLOGY. 

by  nitrate  of  silver  (gr.  x-^j)  applied  to  the  vulva  ;  bismuth  or 
borax  being  dusted  on  between  the  lotions. 


II.  Gonorrheal  Vulvitis. 

What  is  the  etiology  ? 

It  is  produced  either  directly  by  intercourse  with  one  who  has 
contracted  gonorrhoea,  or  indirectly  by  soiled  linen,  instruments,  etc. 

What  is  the  diagnostic  value  of  Neisser's  gonococcus,  found 
in  the  discharge  ? 
Dr.  W.  J.   Sinclair,  in  his  work  on  "Gonorrhoeal  Infection  in 
Women,"  arrives  at  the  following  conclusions  : — 

1 .  "If  gonococci  are  present  in  the  discharge  from  an  inflamed 
mucous  membrane,  the  discharge  is  of  gonorrhoea!  origin. ' ' 

2.  "A  secretion  containing  gonococci,  when  brought  into  contact 
with  a  mucous  membrane  capable  of  infection,  gives  rise  with  cer- 
tainty to  a  gonorrhoea!  inflammation  ;  and  conversely,  a  secretion, 
whatever  its  origin  may  be,  which  does  not  contain  gonococci,  is 
incapable  of  giving  rise  to  a  gonorrhoeal  inflammation. ' ' 

What  is  the  differential  diagnosis  between  gonorrhoeal  vul- 
vitis and  acute  simple  catarrhal  vulvitis  ? 
In  gonorrhoeal  vulvitis,  the  onset  is  more  violent ;  more  fever, 
pain  and  oedema ;  the  inflammation  extends  up  the  vagina  and 
urethra  ;  pus  can  often  be  pressed  out  of  urethra  ;  gonococci  can  be 
found  in  the  discharge  ;  often  warts  or  buboes  are  present,  and 
sometimes  gonorrhoeal  rheumatism. 

What  is  the  treatment  of  gonorrhoeal  vulvitis  ? 

Keep  patient  quiet ;  give  light  diet ;  keep  bowels  open  ;  irrigate 
parts  with  bichloride  1-1000  or  2000,  or  creolin  1-100  or  200  ;  then 
dust  with  calomel,  bismuth,  or  borax.  If  discomfort  is  very  great, 
lead  and  opium  wash  may  be  frequently  applied  to  the  vulva,  and 
patient  may  take  warm  sitz-baths.  The  labia  should  be  kept  sepa- 
rated with  lint  or  gauze  smeared  with  some  simple  antiseptic  oint- 
ment. 

If  the  vulvitis  tends  to  become  chronic,  apply  nitrate  of  silver, 


VULVITIS.  65 

III.  Phlegmonous  Vulvitis. 

What  is  the  etiology  ? 

It  may  arise  from  the  following  : — 
Traumatism  ; 
Irritating  discharges  ; 
Acute  exanthemata  ; 
Furunculosis. 

What  are  the  symptoms  ? 

a.  Subjective  :  Heat  and  pain,  increased  by  standing  or  walking. 

b.  Objective  :    Congestion,  swelling,  induration  ;    later,  suppura- 

tion. 

From  what  must  you  differentiate  phlegmonous  vulvitis  ? 

a.  Pudendal  hernia  ; 

b.  Dislocated  ovary ; 

c.  Hydrocele  of  round  ligament ; 

d.  Hsematoma  of  vulva. 

How  would  you  differentiate  phlegmonous  vulvitis  from  pu- 
dendal hernia  ? 

Phlegmonous  Vulvitis         vs.  Pudendal  Hernia. 

Signs  of  acute  inflammation.  None    unless    strangulated,    or 

injured. 
Dullness  on  percussion.  Tympanitic  on  percussion. 

No  impulse  on  coughing.  Impulse  on  coughing. 

Not  reducible.  Usually  reducible. 

History  of  traumatism,  etc.  History  of  strain. 

How  would  you  differentiate  phlegmonous  vulvitis  from  a 
dislocated  ovary  ? 

Phlegmonous  Vulvitis         vs.  Dislocated  Ovary. 

Signs  of  acute  inflammation.  Usually  absent. 

Gradual  development.  Sudden  development. 

No  especial  exacerbation  during  Larger  and  more  sensitive  during 

menstruation.  menstruation. 

No  sense  of  ovarian  compression  Peculiar  sensation  when  pressed. 

when  pressed  upon. 

Not  the  shape  of  an  ovary.  Has  the  shape  of  an  ovary. 
5 


66  ESSENTIALS  OF  GYNAECOLOGY. 

How  would  you  differentiate  phlegmonous  vulvitis   from 
hydrocele  of  the  round  ligament  ? 
Phlegmonous  Vulvitis  vs.  Hydrocele  of  Round  Ligament. 

Signs  of  acute  inflammation.  No  signs  of  acute  inflammation. 

Opaque.  Translucent. 

Never   communicates  with    ab-       Sometimes  communicates  with 
dominal  cavity.  abdominal  cavity. 

How  would  you   differentiate  phlegmonous  vulvitis   from 
haematoma  of  vultfa  ? 
Phlegmonous  Vulvitis  vs.  Hcematoma  of  Vulva. 

Gradual  formation.  Sudden  onset. 

Less    frequent    during    parturi-      More  frequent   during  parturi- 
tion, tion. 
First  hard,  then  soft.                          First  soft,  then  hard, 
Less  often  preceded  by  varicosi-      More  often  preceded  by  varicosi- 
ties, ties. 

What  is  the  treatment  of  phlegmonous  vulvitis  ? 

Tonics  :  Arsenic,  quinine,  etc. 

Sedatives  :  Hot  lead  and  opium. 

When  pus  formed,  open,  drain  and  dress  antiseptically. 

IV.  Diphtheritic  Vulvitis. 

Give  the  etiology,  symptoms  and  treatment. 

Diphtheritic  vulvitis  is  an  expression  of  constitutional  diphtheria  ; 
the  membrane  sometimes  appears  first  on  vulva  ;  it  resembles  that 
usually  found  in  the  throat.  The  constitutional  symptoms  are  those 
of  diphtheria,  and  should  be  treated  as  such ;  the  local  condition 
demands  antiseptics. 

V.  Gangrenous  Vulvitis. 
Give  the  etiology  and  treatment. 

Gangrenous  vulvitis  is  most  frequently  found  complicating  preg- 
nancy, severe  types  of  acute  exanthemata,  and  very  violent  rases  of 
vulvitis  of  other  varieties.  The  treatment  consists  of  constitutional 
tonics  and  local  antiseptics. 


VULVITIS.  67 

VI.  Follicular  Vulvitis. 

Give  the  pathology. 

Follicular  vulvitis  is  an  inflammation  of  the  mucous  and  sebaceous 
glands  and  hair  follicles  of  the  vulva  ;  all  may  be  simultaneously 
affected,  or  one  set  alone  involved. 

What  is  the  etiology  ? 

It  occurs  only  in  adults  ;  any  of  the  causes  of  simple  acute  catarrhal 
vulvitis  may  produce  it ;  among  the  most  common  are  the  follow- 
ing :— 

a.  Lack  of  cleanliness  ; 

b.  Discharges  from  above,  especially  senile  leucorrhoea ; 

c.  Pregnancy  ; 

d.  Acute  exanthemata. 

What  are  the  symptoms  ? 

a.  Subjective  :— 
Local  heat  and  pain  ; 
Pruritus  ; 

Increased  secretion ; 
Hyperesthesia ; 
Vaginismus  occasionally  present ; 

Vulvar  extremity  of  urethra  is  sometimes  affected,  then  ardor 
urinae  results. 

b.  Objective : — 

The  mucous  membrane  appears  very  red  in  spots,  resembling  the 
papillae  of  the  tongue.  When  the  sebaceous  glands  and  hair  follicles 
are  chiefly  affected,  they  will  be  found  as  little  round  red  papillae,  scat- 
tered over  labia  and  base  of  prepuce  and  clitoris,  not  on  vestibule  ; 
later,  a  drop  of  pus  appears  in  the  apex  of  these  papillae  ;  they  then 
disappear. 

How  would  you  treat  a  case  of  follicular  vulvitis? 

Pay  strict  attention  to  cleanliness ;  during  the  acute  stage  use 
sedative  lotions,  as  lead  and  opium  wash  ;  later,  apply  nitrate  of  silver 
(gr.  x-^j).  Bismuth  or  calomel  may  be  used  as  a  dusting  powder  •, 
keep  labia  separated. 


68  ESSENTIALS  OF  GYNAECOLOGY. 

Cyst  and  Abscess  of  Vulvo- vaginal  Gland. 

Cyst  of  Vulvo-vaginal  Gland. 

Give  the  etiology  and  pathology. 

A  cyst  of  the  Bartholinian  or  vulvo-vaginal  gland  is  formed  by  a 
distention  of  the  duct,  or  gland  itself,  caused  by  any  occlusion  of  the 
duct,  especially  from  inflammation,  either  simple  catarrhal  or  gon- 
orrhoeal.  A  cyst  of  the  duct  is  more  elongated  than  of  the  gland 
itself ;  a  cyst  of  the  gland  is  occasionally  multiple. 

Abscess  of  the  Vulvo-vaginal  Gland. 

What  is  the  etiology  ? 

The  causes  of  a  vulvitis  may  produce  abscess  of  the  vulvo-vaginal 
gland  ;   gonorrhoea  is  the  most  common  cause. 

What  are  the  symptoms  ? 

Pain  ;  heat ;  swelling  and  redness,  especially  near  orifice  of  duct ; 
it  is  tender  on  pressure  ;  at  first  hard,  later  fluctuating. 

How  could  you  differentiate  a  cyst  from  an  abscess  of  the 
vulvo-vaginal  gland  ? 

Cyst  vs.  Abscess. 

Gives  no  signs  of  inflammation.       Shows  inflammation . 
Insensitive  to  pressure.  Sensitive  to  pressure. 

Duration  long.  Duration  shorter. 

What  is  the  treatment  of  a  cyst  of  the  vulvo-vaginal  gland  ? 

The  usual  treatment  is  to  excise  an  elliptical  area  of  mucous  mem- 
brane over  the  sac  on  its  inner  surface  ;  this  exposes  the  sac ; 
now  cut  out  a  large  ellipse  from  it ;  empty  the  sac,  pack  it  with 
iodoform  gauze,  and  apply  an  antiseptic  outside  dressing. 

A  better  plan  is  usually  to  dissect  out  the  whole  sac,  if  possible, 
and  bring  together  the  edges  of  the  wound  with  catgut ;  then  apply 
an  antiseptic  dressing  as  before. 

From  what  may  you  get  considerable  hemorrhage  in  extir- 
pating the  sac  ? 
From  the  transversus  perinei  artery,  and  from  the  bulbs  of  the 
Vagina, 


PUDENDAL  HERNIA.  69 

How  would  you  treat  an  abscess  of  the  vulvo-vaginal  gland  ? 

Before  the  presence  of  pus  is  detected,  keep  the  patient  quiet  in 
bed  ;  apply  soothing  lotions  like  hot  lead  and  opium  wash.  As  soon 
as  pus  is  detected,  proceed  as  with  the  cyst  till  sac  is  opened,  then 
with  a  sharp  curette  scrape  the  interior  of  sac  wall ;  irrigate  with 
bichloride  (1-1000)  ;  pack  with  iodoform  gauze,  and  apply  an  anti- 
septic outside  dressing  of  iodoform  gauze,  bichloride  gauze,  absorbent 
cotton  and  a  T-bandage. 

From  what  must  you  differentiate  vulvo-vaginal  cyst  or 
abscess? 

From  hernia  and  phlegmonous  vulvitis. 

How  would  you  differentiate  vulvo-vaginal  cyst  or  abscess 
from  hernia  ? 

Cyst  or  Abscess  vs.  Hernia. 

No  impulse  on  coughing.  Impulse  on  coughing. 

Irreducible.  Usually  reducible. 

Dull  on  percussion.  Tympanitic  on  percussion. 

Abscess  shows  signs  of  inflam-  None,   unless    strangulated,   or 

mation.  injured. 

More  circumscribed.  Less  circumscribed. 

How  would  you  differentiate  abscess  of  vulvo-vaginal  gland 
from  phlegmonous  vulvitis  ? 
The  vulvo-vaginal  abscess  is  more  distinctly  circumscribed  and 
globular  ;  the  phlegmonous  vulvitis  is  more  diffuse. 


Pudendal  Hernia. 

Describe. 

The  process  of  peritoneum  which  follows  the  round  ligament 
through  the  inguinal  canal  to  its  termination  in  the  labium  majus  is 
usually  obliterated  at  birth ;  occasionally  this  obliteration  does  not 
occur,  and  this  channel,  called  the  canal  of  Nuck,  furnishes  a  path 
for  hernia.  The  hernia  may  consist  of  intestine,  omentum,  ovary  o* 
bladder.     The  uterus  has  even  been  said  to  follow  this  canal. 

What  are  the  causes  ? 

Blows,  falls,  coughing  or  violent  muscular  exertion. 


70  ESSENTIALS   OF  GYNECOLOGY. 

What  are  the  symptoms  ? 

The  patient  experiences  a  feeling  of  discomfort,  especially  on 
walking,  and  finds  a  swelling,  which,  if  intestine,  presents  the  fol- 
lowing features :  It  gives  an  impulse  on  coughing ;  is  tympanitic 
on  percussion ;  can  usually  be  reduced,  and,  unless  strangulated, 
or  injured,  presents  no  signs  of  inflammation. 

If  the  hernia  consists  of  an  ovary,  it  gives  the  ovarian  sensation 
on  pressure,  and  its  size  and  tenderness  are  both  increased  during 
menstruation. 

What  is  the  treatment  ? 

Place  patient  on  her  back,  with  knees  elevated  ;  reduce  by  gentle 
taxis,  if  possible,  and  apply  a  suitable  truss.  If  strangulation  has 
occurred,  a  surgical  operation  is  necessary.  If  the  hernia  consists 
of  an  ovary  which  has  become  adherent,  protect  it  from  pressure  by 
a  hollow  pad,  or  if  it  occasions  great  distress,  remove  it. 


Pudendal  Hematocele. 

What  are  the  synonyms  ? 

Haematoma  or  thrombus  of  vulva. 

Define. 

Pudendal  hematocele  consists  of  an  effusion  of  blood  into  the 
tissue  of  the  vulvo-vaginal  region,  usually  into  one  labium,  or  into 
the  areolar  tissue  surrounding  the  vaginal  walls. 

What  is  the  etiology  ? 

Pudendal  hematocele  is  piedisposed  to  by  any  condition  causing., 
or  accompanied  by,  a  dilatation  of  the  vessels  of  the  vulva  : — 

Pregnancy ; 
Tumors ; 
Varicocele ; 
Labor. 

The  exciting  causes  are  blows,  falls,  muscular  efforts,  eta 

Describe  the  symptoms  and  course. 
The  patient  experiences  pain  of  a  tearing  character,  which,  if  the 


HEMORRHAGE  FROM  VULVA.  71 

effusion  is  large,  may  be  accompanied  by  faintness.  Sometimes  the 
effusion  presses  on  the  urethra  and  causes  difficulty  in  micturition. 
The  swelling  is  at  first  soft ;  later,  hard. 

If  small,  it  is  usually  absorbed  ;  it  sometimes  remains  for  a  long 
time  ;  sometimes  suppurates. 

How  would  you  differentiate   pudendal  hematocele  from 
hernia  ? 

Pudendal  Hematocele  vs.                   Hernia. 

History.  History. 

No  impulse  on  coughing.  Impulse  on  coughing. 

Dull  on  percussion.  Tympanitic. 

Irreducible.  Usually  reducible. 

First  soft,  then  hard.  More  uniform. 

How  would  you  treat  a  case  of  pudendal  hematocele  ? 

While  effusion  is  in  progress,  apply  ice  and  pressure.  If  the 
effusion  is  large,  occurs  during  labor  and  obstructs  the  passage  of  the 
head,  incise,  turn  out  the  clots  and  pack  with  iodoform  gauze.  If 
the  effusion  is  small,  apply  soothing  lotions  like  lead  and  opium 
wash  ;  if  suppuration  occurs,  or  if  absorption  is  long  delayed,  incise, 
irrigate  with  bichloride  1-1000,  and  pack  with  iodoform  gauze. 


Hemorrhage  from  Vulva. 

What  is  the  etiology  ? 

The  predisposing  causes  are  the  same  as  for  pudendal  haemato- 
cele  and  hsernatocele  itself.   The  existing  causes  are  the  following  : — 
Violent  muscular  efforts ; 
Blows  ; 
Punctures  or  lacerations. 

What  is  the  treatment  ? 

If  it  is  a  ruptured  haematocele,  incise,  turn  out  the  clots  and  pack  ; 
otherwise,  catch  bleeding  points  and  ligature,  or  apply  pressure, 
assisted  by  a  tampon  in  the  vagina. 


72  ESSENTIALS  OF  GYNECOLOGY. 


Skin  Diseases  Affecting  the  Vulva. 

What  are  the  most  common? 

Erythema  and  eczema  are  most  frequently  seen  ;  the  latter  may 
be  acute  or  chronic. 


Erythema  of  the  Vulva. 

Give  the  etiology,  symptoms  and  treatment. 

Etiology. — Erythema  is  most  apt  to  occur  in  fleshy  people,  espe- 
cially in  hot  weather.     The  exciting  causes  are  : — 
Lack  of  cleanliness ; 
Irritating  discharges  ; 
Exercise. 
Symptoms. — The  parts  become  red,  sensitive,  often  excoriated  and 
painful,  especially  in  walking. 
Treatment. — Cleanliness ; 

Attention  to  bladder  and  urine  ; 
Desiccating  powders,   such  as   bismuth,   borax  or 
oxide  of  zinc. 


Eczema  of  the  Vulva. 

Give  the  etiology. 

Eczema  is  predisposed  to  by  functional  disturbance  of  the  gastro- 
intestinal tract,  gout  or  rheumatism  ;  it  is  especially  apt  to  occur  in 
women  near  the  menopause.  The  mo^t  frequent  exciting  cause  is 
an  irritating  discharge  from,  the  cervix  or  vagina. 

What  are  the  symptoms  ? 

The  disease  may  be  acute  or  chronic.  In  the  acute  form,  the  parts 
become  reddened  and  oedematous  ;  vesicles  appear,  break  and  dis- 
charge a  thick,  tenacious  fluid,  which  forms  crusts.  The  subjective 
symptoms  are  severe  burning  and  itching. 

In  the  chronic  form,  the  parts  become  thickened  and  scaly ;  the 
subjective  symptoms  resemble  those  of  the  acute,  but  are  a  little 
less  marked. 


ECZEMA   OF  THE  VULVA.  73 

What  is  the  treatment  ? 

In  the  acute  form,  observe  strict  cleanliness  ;  if  the  burning  is  very 
severe,  use  lead  and  opium  wash  ;  later,  or  at  first,  if  burning  and 
itching  are  not  intense,  an  ointment  like  the  following  is  very 
good : — 

R.    Acidi  salicylici, gr.  xv, 

Zinci  oxidi, gij j  ss, 

Pulv.  amyli, %  ij  ss, 

Petrolati, %]. 

M.    Sig. — Apply  locally. 

In  the  chronic  form,  use  the  same  treatment  during  the  exacerba- 
tions as  for  the  acute  ;  later,  an  ointment  containing  oil  of  cade  will 
be  found  of  value. 

What  are  the' most  common  parasites  found  on  the  vulva  ? 

The  pediculus  pubis,  or  crab  louse,  is  the  parasite  most  often  found 
infecting  the  vulva. 

The  acarus  scabiei,  or  itch  mite,  is  occasionally,  but  rarely,  found 
on  the  vulva  as  part  of  a  general  infection. 

Give  the  etiology,  symptoms  and  treatment  of  infection  with 
pediculi  pubis. 

Etiology. — The  pediculus  pubis  is  almost  always  conveyed  directly 
from  person  to  person,  usually  in  sexual  intercourse. 

Symptoms. — There  is  burning  and  itching ;  often  an  eruption 
resembling  eczema.  The  diagnosis  is  made  by  finding  the  pediculus 
closely  adherent  to  the  roots  of  the  hair. 

Treatment. — Any  one  of  the  following  : — 

Oleate  of  mercury,  10  per  cent.; 
Corrosive  sublimate,  1-1000 ; 
Tincture  of  delphinium  ; 
Carbolic  5  per  cent,  solution. 

It  is  often  best  to  shave  the  pubes  before  applying  the  lotion  or 
ointment. 

Give  the  etiology,  symptoms  and  treatment  of  scabies  of  the 
vulva. 

Etiology. — The  acarus  scabiei  is  rarely  found  on  the  vulva,  but 
this  occasionally  occurs  as  part  of  a  general  infection. 


74  ESSENTIALS   OP  GYNECOLOGY. 

Symptoms. — There  is  an  intense  pruritus,  worse  when  the  body  is 
warm.  The  diagnosis  is  made  by  finding  the  burrows  on  other  parts 
of  the  body,  especially  between  the  fingers. 

Treatment. — A  warm  soap  and  water  bath,  followed  by  an  oint- 
ment composed  of  sulphur  alone,  or  combined  with  balsam  of  Peru. 


New  Growths  of  the  Vulva. 

Mention  the  principal  new  growths  occurring  on  the  vulva? 

a.  Papillomata — 

1.  Simple ; 

2.  Pointed  condylomata ; 

3.  Syphilitic  condylomata. 

b.  Cyst  of  vulvo-vaginal  gland. 

c.  Carcinoma. 

d.  Sarcoma. 

e.  Elephantiasis. 
/  Fibromata. 

g.  Lipomata. 
h.  Neuromata. 
i.  Lupus. 


Simple  Papillomata. 

What  is  the  etiology  and  treatment  ? 

Etiology. — A  simple  papilloma,  or  wart,  occurs  rarely  on  the 
vulva  ;  it  is  usually  congenital  and  of  little  importance. 

Treatment. — It  may  be  destroyed  with  nitric  acid,  or  it  may  be 
excised  under  cocaine,  and  the  wound  closed  with  fine  sutures. 


Pointed  Condylomata. 

What  is  the  etiology  and  appearance  ? 

Pointed  condylomata,  or  gonorrheal  warts,  are  caused  by  the 
gonorrhoeal  poison  ;  they  are  always  multiple,  and  occur  most  fre- 
quently on  the  inner  surfaces  of  the  labia  inajora,  on  the  vestibule 
and  perineum  ;  they  are  of  a  grayish  color  and  often  pediculated; 


PRURITUS  VULVAE.  75 

their  summit  is  divided  into  pointed  lobules.  When  on  the  skin, 
they  are  sometimes  dry  and  hard ;  on  a  mucous  surface  they  are 
soft.  In  some  cases  pointed  condylomata  appear  to  arise  from  an 
irritating  discharge,  the  gonorrhoeal  character  of  which  cannot  be 
proved. 

What  is  the  treatment  of  pointed  condylomata  ? 

The  best  treatment  is  to  cut  them  off  with  scissors  or  knife  and 
touch  the  base  with  nitric  acid  ;  under  the  use  of  cocaine  this  may 
he  made  practically  painless. 

Syphilitic  Condylomata. 

What  is  the  etiology,  appearance  and  treatment  ? 

Syphilitic  condylomata,  or  mucous  patches,  are  the  result  of  the 
syphilitic  poison.  They  are  broad  and  flat,  situated  most  frequently 
on  the  inner  surface  of  the  labia  majora,  and  usually  covered  with  a 
grayish,  mucus-like  secretion.  According  to  Duhring,  they  some- 
times take  on  a  more  warty  growth. 
Treatment — Cleanliness ; 

Calomel  locally ; 

Constitutional  treatment  for  syphilis. 

Pruritus  Vulvae. 

Define. 

Pruritus  vulvae,  a  symptom  rather  than  a  disease  per  se,  consists 
<of  an  irritation  of  the  nerves  of  the  vulva,  accompanied  by  intense 
itching,  at  first  localized,  later  extending,  from  the  mechanical  irrita- 
tion of  scratching. 

What  is  the  etiology  ? 

The  predisposing  causes  are  : — 

a.  Poor  health. 

b.  Disorders  of  the  digestive  tract. 

c.  Anything  producing  congestion  of  the  vulva,  such  as— 

Pregnancy  ; 

Tumors  in  neighborhood ; 

Diseases  of  uterus  or  appendages ; 

Menopause. 


76  ESSENTIALS  OF  GYNECOLOGY. 

d.  Lack  of  cleanliness. 

The  exciting  causes  are  chiefly  the  following : — 

1 .  Irritating  discharges  from  cervix,  vagina,  urethra  or  vulva. 

2.  Diabetic  urine. 

3.  Eruptions. 

4.  Parasites. 

5.  Masturbation. 

6.  Vegetations  on  vulva. 

What  are  the  symptoms  ? 

An  intense  itching,  at  first  only  at  intervals  after  active  exercise, 
over-indulgence  at  the  table,  lying  in  a  warm  bed,  or  sexual  inter- 
course. Later,  the  itching  becomes  constant ;  the  desire  to  scratch 
becomes  irresistible,  causing  the  patient  to  avoid  society ;  it  some- 
times leads  to  nervous  depression  and  melancholia. 

What  is  the  treatment  ? 

First  ascertain  the  cause,  if  possible. 

Build  up  the  general  health. 

Regulate  the  diet. 

Observe  strict  cleanliness. 

Destroy  parasites  if  present. 

If  sugar  present  in  the  urine,  give  salicylate  of  soda. 

Treat  eruptions. 

If  there  is  an  acid  discharge  from  above,  tampon  vagina. 

Let  patient  use  frequent  warm  sitz-baths. 

Apply  any  one  of  the  following  : — 

Hot  lead  and  opium  wash  ; 

Carbolic  solution,  2-3  per  cent. ; 

Bismuth  or  borax  dusted  on  vulva ; 

Nitrate  of  silver  (gr.  x-^j) ; 

Cocaine,  4  per  cent,  solution. 


VAGINISMUS.  77 

Hyperesthesia  of  the  Vulva. 

Describe. 

This  consists  of  an  excessive  sensibility  of  the  nerves  supplying  the 
mucous  membrane  of  some  portion  of  the  vulva. 

What  is  the  etiology  ? 

The  menopause  seems  to  predispose  to  it ;  also  the  hysterical  and 
melancholic  state.  An  irritable  urethral  caruncle  sometimes  acts  as 
an  exciting  cause.     Often  no  cause  can  be  assigned. 

What  are  the  symptoms  ? 

Hyperesthesia,  especially  about  the  vestibule  and  labia  minora ; 
there  is  no  pruritus,  and  signs  of  inflammation  are  absent  except 
occasional  erythematous  spots ;  dyspareunia  is  very  marked ;  the 
slightest  friction  causes  pain. 

What  is  the  treatment  ? 

Build  up  the  constitution  with  tonics,  change  of  air,  etc. 
Interdict  sexual  intercourse. 
Administer  the  bromides  internally. 
Externally  apply  one  of  the  following  : — 

Carbolic  lotion,  2-3  per  cent ; 

Lead  and  opium  wash  ; 

Four  per  cent,  solution  of  cocaine. 


Vaginismus. 
Define. 

Sims  defined  vaginismus  as  ' '  an  excessive  hyperesthesia  of  the 
hymen  and  vulvar  outlet,  associated  with  such  involuntary  spasmodic 
contraction  of  the  sphincter  vaginae  muscle  as  to  prevent  coitus. ' ' 

What  is  the  pathology? 

There  are  usually  found  sensitive  papillae  about  the  base  of  the 
hymen  ;  an  hypertrophy  of  the  papillae  and  connective  tissue  of  the 
hymen  ;  occasionally  the  lesion  seems  to  be  at  a  distance,  as  in  the 
uterus  or  appendages  ;  sometimes  no  lesion  is  visible. 


78  ESSENTIALS  OF  GYNAECOLOGY. 

What  is  the  etiology  ? 

The  predisposing  causes  are — 

1.  A  narrow  vagina. 

2.  A  dense,  thick  hymen. 

3.  Malposition  of  the  vulva. 
The  exciting  causes  are — 

1 .  Disturbances  of  the  sexual  function. 

2.  Masturbation. 

3.  Inability  of  the  male  to  complete  the  sexual  act. 

What  is  the  treatment  ? 

Palliative. — Forcibly  dilate  the  hymen,  under  anaesthesia,  by  insert- 
ing and  separating  the  thumbs  ;  then  insert  one  of  Sims'  gkss 
vaginal  plugs. 

Radical. — Excise  the  hymen  and  insert  one  of  Sims'  plugs. 

Coccygodynia. 

Define  and  give  the  etiology. 

Coccygodynia,  or  coccyodynia,  is  a  "  painful  affection  of  the  mus- 
cles, tendons,  and  nerves  of  the  coccyx,  with  or  without  disease  of 
the  bone  itself. "     (Mann). 

It  occurs  most  frequently  after  childbirth,  but  is  also  produced  by 
mechanical  causes,  such  as  blows,  falls,  kicks,  etc.  Among  other 
causes  are  disease  of  the  pelvic  organs,  rheumatism  and  gout.  Hys- 
teria largely  predisposes  to  it ;  in  some  cases  no  cause  can  be  assigned. 

What  are  the  symptoms  ? 

Pain  in  the  coccygeal  region,  increased  by  motion  bringing  into 
play  the  muscles  attached  to  the  coccyx ;  especially  rising  after  sit- 
ting, defecation,  coitus,  sometimes  even  walking. 

Pressure  on  the  coccyx  elicits  the  characteristic  pain. 

The  condition  must  be  differentiated  from  disease  of  the  rectum 
or  anus,  and  from  pure  hysteria. 

What  is  the  treatment  ? 

First  attend  to  the  general  condition,  rheumatism,  hysteria,  etc.s 
if  this  fails,  we  have  two  operations  : — 

1 .  Cutting  the  attachments  of  the  muscles  to  the  coccyx. 

2.  Extirpation  of  the  coccyx. 


IRRITABLE  URETHRAL  CARUNCLE.  79 

Irritable  Urethral  Caruncle. 

Define. 

An  irritable  urethral  caruncle  is  a  deep  red  mass,  very  vascular 
and  sensitive,  situated  at  the  mouth  of  the  urethra,  or  just  within 
the  canal ;  it  consists,  according  to  Hart  and  Barbour,  of  dilated  capil- 
laries in  connective  tissue,  the  whole  being  covered  with  squamous 
epithelium. 

What  is  the  etiology  ? 

But  little  is  known  of  its  etiology  ;  it  occurs  at  all  ages,  and  in 
both  married  and  single  women. 

What  are  the  symptoms  ? 

The  patient  complains  of  frequent  and  painful  micturition  ;  later, 
this  dysuria  increases,  and  pain  is  caused  by  walking,  pressure  or 
friction  of  any  kind.  Intercourse  causes  both  pain  and  hemorrhage. 
The  nervous  symptoms  are  well-marked  ;  hysteria,  melancholia,  etc. 

On  examination,  one  finds  a  raspberry-looking  mass  at  the  meatus  ; 
it  is  very  sensitive  and  bleeds  easily  ;  it  may  be  single  or  multiple. 

From  what  must  you  differentiate  an   irritable   urethral 
caruncle,  and  how  ? 

From  polypi,  venereal  warts  and  prolapse  of  the  urethral  mucous 
membrane. 

Polypi  are  usually  higher  in  the  urethra,  are  less  vascular  and 
less  sensitive. 

Yenereal  warts  are  less  vascular,  insensitive,  and  usually  accom- 
panied by  others.     The  history  may  aid. 

Prolapse  of  the  urethral  mucous  membrane  may  resemble  a 
caruncle  in  appearance,  but  it  usually  surrounds  the  meatus  more,  is 
less  vascular  and  less  sensitive,  is  continuous  with  the  urethral 
mucous  membrane,  and  can  usually  be  reduced. 

What  is  the  treatment  ? 

Employ  anaesthesia  ;  cut  off  the  caruncle  and  touch  the  base  with 
nitric  acid  or  the  actual  cautery.     You  may  ligate  before  cutting. 

What  is  the  prognosis  ? 

If  the  growth  is  single  and  near  the  meatus,  the  pre  gnosis  is  good ; 
if  multiple  and  extending  up  the  urethra,  they  may  recur. 


80  ESSENTIALS  OF  GYNECOLOGY. 

Prolapse  of  the  Urethral  Mucous  Membrane. 

Describe. 

Prolapse  of  the  urethral  mucous  membrane  may  involve  the  whole 
circumference  of  the  meatus,  or  only  a  portion  ;  if  the  latter,  it  is 
the  lower  portion  which  is  usually  affected  ;  a  slight  redundancy  at 
the  meatus  is  common  ;  a  prolapse  sufficient  to  form  a  tumor  is  rare. 
At  first  the  exposed  mucous  membrane  is  of  its  normal  pink  color  ; 
later  it  assumes  an  angry  red  color,  often  becomes  excoriated  and 
sensitive  ;  urethritis  and  cystitis  may  result. 

What  is  the  etiology  ? 

Frequent  child-bearing,  dilatation  of  the  urethra  and  a  lax  condi- 
tion of  the  tissue,  from  whatever  cause,  undoubtedly  predispose  to 
prolapse  of  the  urethral  mucous  membrane.  The  exciting  causes 
are  usually  vesical  and  rectal  irritation,  accompanied  by  straining. 

What  are  the  symptoms  ? 

Frequent  micturition,  which  soon  becomes  painful,  tenesmus,  and 
if  vesical  tenesmus  previously  existed,  it  becomes  much  aggravated. 

What  is  the  treatment  ? 

If  the  prolapse  is  recent,  an  attempt  at  cure  may  be  made  by 
reducing  the  mucous  membrane,  keeping  the  patient  quiet  in  bed, 
making  astringent  applications  to  the  urethra  and  removing  the 
cause  of  previous  vesical  or  rectal  tenesmus,  if  present. 

If  these  procedures  fail,  remove  the  prolapsed  portion  by  one  of 
the  following  methods  : — 

1.  Ligate  and  excise. 

2.  Remove  with  a  galvano-caustic  wire,  and  keep  catheter  in  the 
bladder  for  a  few  days. 

3.  Emmet's  "button-hole"  operation. 

Malformations  of  the  Vulva. 

What  are  the  principal  malformations  of  the  vulva  ? 

1 .  Absence  of  the  vulva. 

2.  Hypospadias,  in  which  the  posterior  wall  of  the  urethra  is 
defective. 


SIMPLE   CATARRHAL   VAGINITIS.  81 

3.  Epispadias,  in  which  the  anterior  urethral  wall  is  defective, 
usually  combined  with  a  defect  in  the  anterior  wall  of  the  bladder. 

4.  The  clitoris  may  be  absent,  rudimentary,  or  hypertrophied. 

5.  The  labia  majora  may  be  absent,  rudimentary,  or  greatly  hyper- 
trophied, as  in  the  l '  Hottentot  apron. ' ' 

6.  Less  often  the  labia  majora  may  be  hypertrophied. 

7.  True  hermaphroditism,  where  both  an  ovary  and  a  testicle  exist 
in  the  same  person,  although  very  rare,  is  said  to  occur  in  a  few  cases. 

8.  Pseudo-hermaphroclitism,  where   the  external  genitals  alone 
resemble  those  of  both  sexes,  is  more  common. 

Diseases  of  the  Vagina. 

What  are  the  varieties  of  inflammation  of  the  vagina  ? 

1.  Simple  catarrhal  vaginitis,  or  colpitis. 

2.  G-onorrhoeal. 

3.  Ulcerative,  senile  or  adhesive. 

4.  Diphtheritic. 

Simple  Catarrhal  Vaginitis. 

What  is  the  etiology  ? 

The  predisposing  causes  are — 

a.  General  bad  health. 

b.  Anything  causing  local  congestion,  as — 

Disease  of  heart  or  lungs  ; 
Disease  of  the  pelvic  organs  ; 
Pregnancy. 
The  exciting  causes  are  : — 

a.  Irritating  discharges  from  the  cervix. 

b.  The  use  of  too  hot,  too  cold  or  irritating  douches. 

c.  Awkward  or  excessive  coitus. 

d.  Foreign  bodies,  as  pessaries,  tampons,  etc. 

What  are  the  symptoms  ? 

Simple  catarrhal  vaginitis  may  be  acute  or  chronic. 

The  subjective  symptoms  of  the  acute  are  a  feeling  of  heat  in  the 
vagina,  pain  in  the  pelvis,  and  sometimes  vesical  and  rectal  irrita- 
bility. 
6 


82  ESSENTIALS   OP  GYNECOLOGY. 

The  objective  symptoms  are  a  muco-purulent  vaginal  discharge 
which  may  irritate  the  vulva ;  the  vagina  appears  red,  perhaps  gran 
ular  or  cystic  in  places. 

The  chronic  form  resembles  the  acute  except  in  degree  ;  in  it  the 
subjective  symptoms,  save  itching  caused  by  the  leucorrhoea,  are 
usually  absent. 

What  is  the  treatment  of  simple  catarrhal  vaginitis  ? 

In  the  early  stages,  keep  the  patient  quiet ;  keep  the  bowels  open, 
and  give  light  diet ;  if  there  is  much  pain,  allow  an  opium  supposi- 
tory; keep  the  urine  bland  by  alkaline  diluents.  If  the  itching  is  severe, 
let  the  patient  take  frequent  warm  alkaline  sitz-baths  ;  in  addition, 
irrigation  of  the  vagina  with  warm  water  containing  either  of  the 
following  will  be  found  of  value  :  Liquor  plumbi  subacet,  3j-Oj  ; 
borax  3j-Oj. 

After  irrigation  it  is  well  to  dust  some  desiccating  powder,  like 
borax,  upon  the  vulva. 

When  the  vaginitis  becomes  subacute  or  chronic,  make  applica- 
tion to  the  vagina  of  nitrate  of  silver  gr.  x-xxx-^j,  or  pyroligneous 
acid. 

Let  the  patient  use  daily  vaginal  douches  of  hot  water  containing 
borax,  3j-Oj ;  or  sulphate  of  zinc,  3ss-3j-Oj  ;  or  alum,  3j-Oj. 

The  douches  should  be  taken  while  the  patient  is  in  the  dorsal 
position,  not  sitting. 


Gonorrhoea!  Vaginitis. 

How  does  gonorrheal  vaginitis  differ  from  the  simple  catar- 
rhal? 

a.  The  onset  is  usually  more  acute. 

I.  The  discharge  is  more  purulent,  viscid  and  offensive  than  in 
the  simple  catarrhal. 

c.  Urethritis  is  more  common. 

r/.  Sometimes  a  history  of  exposure  to  infection  can  be  ob- 
tained. 

e.  Often  gonorrhoeal  warts  or  buboes  are  present. 

/.  The  most  certain  diagnostic  point  is  the  presence  of  gonococcL 


ULCERATIVE  VAGINITIS.  83 

"What  are  the  frequent  complications  and  results  of  gonor- 
rheal vaginitis  ? 

Vulvitis,  urethritis,  endometritis,  salpingitis,  ovaritis  and  perito- 
nitis. 

The  dangers  of  gonorrheal  vaginitis  have  been  greatly  under- 
estimated. 

What  is  the  treatment  of  gonorrheal  vaginitis  ? 

Keep  patient  as  quiet  as  possible  ;  attend  to  diet,  bowels  and  urine 
as  in  the  simple  catarrhal ;  if  there  is  much  pain  give  an  opium 
suppository  ;  irrigate  vagina  with  warm  bichloride  sol. ,  1-1000-5000, 
then  insufflate  iodoform,  and  insert,  to  keep  vaginal  walls  separated, 
iodoform  gauze  soaked  in  the  following  solution  : — 

Iodoform, 1  part. 

Chloral, 1     " 

Glycerine, .    .  4 

This  gauze  may  be  left  in  6-12  hours.     The  complicating  vulvitis 
may  require  the  regular  treatment  for  gonorrhoeal  vulvitis. 

It  is  well  to  repeat  the  bichloride  vaginal  irrigation  every  day  or 
two  during  the  acute  stage ;  later,  applications  to  the  vagina  of 
nitrate  of  silver,  gr.  x-xxx-gj,  are  of  value. 


Ulcerative  Vaginitis. 

Describe. 

Ulcerative,  senile  or  adhesive  vaginitis  is  present  to  a  greater  or 
less  extent  in  nearly  every  woman  over  60. 

There  is  a  desquamation  of  the  squamous  epithelium  in  spots,  and 
where  these  raw  areas  lie  in  apposition,  adhesion  is  apt  to  occur. 
There  is  usually  a  thin  leucorrhoea,  which  irritates  the  vulva  and 
causes  pruritis. 

What  is  the  treatment  ? 

The  treatment  consists  in  the  application  to  the  vagina  of  such 
solutions  as  nitrate  of  silver,  gr.  x-xx-^j,  or  pyroligneous  acid,  and 
the  use  by  the  patient  of  astringent  vaginal  douches,  such  as  sul- 
phate of  zinc  3ss-Oj,  alum  3j-0j,  or  borax  3j-Oj. 


84  ESSENTIALS   OF  GYNAECOLOGY. 

Diphtheritic  Vaginitis. 

What  is  the  etiology  and  treatment  ? 

Diphtheritic  vaginitis  is  an  expression  of  constitutional  diphtheria, 
with  its  regular  etiology  and  symptoms. 

The  treatment  should  consist  of  local  antiseptics  and  the  con- 
stitutional treatment  for  diphtheria. 

Pelvic  Peritoneum. 

Describe. 

The  pelvic  peritoneum  is  a  continuation  of  that  lining  the  inner 
surface  of  the  walls  of  the  abdomen ;  it  covers,  more  or  less  com- 
pletely, the  pelvic  organs  (the  ovary  is  regarded  as  not  covered  by 
peritoneum),  lines  the  pelvic  walls  and  also  the  floor  of  the  pelvis. 
Traced  from  before  backward,  in  the  median  line,  it  leaves  the 
anterior  abdominal  wall  about  1J  inches  above  the  symphysis,  is 
reflected  over  the  fundus  of  the  bladder  and  down  its  posterior 
surface  to  about  the  level  of  the  internal  os ;  it  then  passes  over 
to  the  uterus,  covers  its  anterior  surface  above  that  point,  passes 
over  the  fundus  and  down  its  posterior  surface  to  the  vaginal 
junction,  thence  down  the  vaginal  wall  for  about  an  inch  ;  it  then 
passes  to  the  rectum,  covers  the  anterior  surface  of  the  middle 
portion,  and  surrounds  the  upper  portion  completely.  The  pelvic 
peritoneum  is  thrown  into  several  folds  and  forms  several  pouches. 

Describe  the  folds  and  pouches  of  the  pelvic  peritoneum. 

The  principal  folds  are  the  broad,  utero-vesical  and  utero-sacral 
ligaments  (so-called).  The  broad  ligaments,  extending  from  the 
sides  of  the  uterus  to  the  sides  of  the  pelvis,  in  front  of  the 
sacro  iiiac  synchondrosis,  divide  it  into  two  fossae,  the  anterior  and 
posterior ;  these  are  also  subdivided,  the  anterior  by  the  utero- 
vesical  ligaments,  the  posterior  by  the  utero-sacral.  The  pouch 
between  the  utero-vesical  ligaments  is  called  the  utero-vesical  pouch ; 
that  between  the  utero-sacral,  the  pouch  of  Douglas,  which  is  the 
deepest  part  of  the  peritoneal  cavity. 

The  pouches  between  the  utero-vesical  and  broad  ligaments  are 
called  the  para-vesical  pouches  ;  those  between  the  utero-sacral  and 
broad  ligaments  are  called  by  Polk  the  "retro-ovarian  shelves." 


PELVIC   PERITONITIS.  85 

Two  other  pouches  are  mentioned,  which  depend  on  the  condition 
of  the  bladder  :  the  vesico-abdominal,  when  the  bladder  is  distended ; 
and  the  utero-abdominal,  when  the  bladder  is  empty  and  contracted 

What  are  the  boundaries  of  the  utero-vesical  pouch  ? 

It  is  bounded  in  front  by  the  posterior  surface  of  the  bladder, 
behind  by  the  anterior  surface  of  the  uterus,  and  laterally  by  the 
utero  vesical  ligaments. 

What  are  the  boundaries  of  the  pouch  of  Douglas  ? 

It  is  bounded  in  front  by  the  posterior  surface  of  the  uterus  and 
the  upper  portion  of  the  posterior  vaginal  wall,  behind  by  the  rec- 
tum, and  laterally  by  the  utero-sacral  ligaments. 

What  are  the  boundaries  of  the  retro-ovarian  shelves  ? 

They  are  triangular  in  shape,  bounded  in  front  by  the  base  of  the 
broad  ligament,  internally  by  the  utero-sacral  ligament,  and  exter- 
nally by  the  wall  of  the  pelvis. 


Pelvic  Peritonitis. 

What  is  the  pathology  ? 

The  peritoneum  first  becomes  hyperaemic  ;  it  loses  its  lustre,  and 
exudation  materials  are  poured  out. 

1.  There  may  be  scarcely  any  serum  exuded  ;  the  inflamed  area 
is  coated  with  fibrin,  and  adhesions  form,  binding  together  the  pelvic 
organs  and  intestines. 

2.  The  exudation  may  consist  largely  of  serum,  either  free  in  the 
peritoneal  cavity,  or  encapsulated  by  adhesions. 

3.  The  exudation  in  severe,  especially  septic  cases  is  often  puru- 
lent. 

Hence  the  varieties  : — 

a.  Adhesive. 

b.  Serous. 
d.  Purulent. 

What  is  the  etiology  ? 

In  a  general  way,  the  etiology  of  pelvic  peritonitis  may  be  stated 
as  an  extension  to  the  peritoneum  of  inflammation  of  the  uterus, 


86  ESSENTIALS   OF  GYNECOLOGY. 

ovaries  or  tubes  ;  in  a  large  majority  of  the  cases,  inflammation  of 
the  tubes. 

There  is,  usually,  first  an  endometritis,  then  a  salpingitis,  and 
then  a  peritonitis. 

Individual  causes  are  as  follows  : — 

a.  Catching  cold  during  menstruation. 

b.  Introduction  into  the  uterus  of  septic  instruments. 

c.  Gonorrhoea. 

d.  Injection  of  fluids  through  uterus  and  tubes  into  the  peritoneal 
cavity. 

e.  Introduction  of  sepsis  during  parturition,  abortion  or  opera- 
tions. 

/.  Tubercular  or  cancerous  disease  of  the  pelvic  organs. 
g.  Pelvic  cellulitis  and  peritonitis  are  often  associated  as  being 
produced  by  the  same  causes. 

What  are  the  symptoms  ? 

Pelvic  peritonitis  may  be  either  acute  or  chronic. 

Acute  pelvic  peritonitis  is  usually  ushered  in  by  a  rigor ;  this, 
however,  is  not  always  present.  There  is  pain  and  tenderness  in  the 
lower  part  of  the  abdomen ;  patient  lies  on  the  back,  with  knees 
elevated  ;  the  pulse  is  small,  wiry  and  rapid  ;  the  temperature  is 
elevated,  sometimes  104°-5°,  usually  lower  ;  nausea  and  vomiting 
are  common ;  more  or  less  tympanites  is  present ;  the  bowels  are 
constipated  ;  there  is  frequently  irritability  of  the  bladder  ;  often 
menorrhagia. 

Chronic  peritonitis  may  exist  and  present  scarcely  any  symptoms 
save  a  dull  pain  in  the  pelvis  ;  usually,  there  is  vesical  and  rectal 
irritability,  dyspareunia,  leucorrhoea,  and  a  disturbance  of  menstrua- 
tion, especially  menorrhagia. 

Chronic  peritonitis  may  follow  the  acute,  or  may  begin  as  chronic. 

Pelvic  peritonitis  is  often  characterized  by  exacerbations. 

What  are  the  physical  signs  of  acute  pelvic  peritonitis  ? 

The  vagina  is  hot  and  dry;  pressure  in  either  fornix,  or  on  the 
abdomen,  is  intensely  painful;  the  bimanual  is  impracticable;  the 
uterus,  tubes  and  ovaries  are  usually  bound  fast;  the  slightest 
attempt  to  move  them  causes  intense  pain.  The  fornices  may  seem 
io  be  covered  by  a  hard,  flit  roof,  formed  by  a  matting  together  of 


PELVIC  CELLULITIS.  87 

the  pelvic  contents,  often  compared  to  plaster-of-Paris  poured  into 
the  pelvis  and  hardened  ;  you  may  feel  a  tumor  close  to  the  uterus, 
consisting  of  serum  or  pus,  roofed  in  by  adhesions ;  the  most  com- 
mon situation  of  this  tumor  is  in  the  pouch  of  Douglas. 

What  are  the  common  results  of  pelvic  peritonitis  ? 

Displacement  of  uterus,  ovaries  and  tubes,  the  tubes  being  often 
distorted  and  stenosed  by  the  traction  of  adhesions  ;  as  a  result  of 
these  conditions  we  get  disturbances  of  menstruation,  sterility  and 
extra-uterine  pregnancy. 

What  is  the  prognosis  of  pelvic  peritonitis  ? 

Simple  adhesive  peritonitis  often  ends  in  complete  recoveiy  ;  dis- 
placement of  the  pelvic  organs  may  remain,  however,  and  give  rise 
to  symptoms.     The  prognosis  of  purulent  peritonitis  is  grave. 

What  is  the  treatment  of  pelvic  peritonitis  ? 

In  the  acute  form,  keep  the  patient  quiet  in  bed,  give  fluid  diet, 
apply  hot  poultices  or  turpentine  stupes  to  the  lower  part  of  the 
abdomen  ;  if  the  temperature  is  very  high,  use  the  cold-water  coil 
instead  of  the  hot  applications  ;  if  there  is  great  pain,  give  a  little 
morphine  ;  after  a  few  days,  move  the  bowels  gently,  as  by  calomel 
gr,  j  every  hour  for  3-4  doses,  assisted,  if  necessary,  by  an  enema. 
After  the  acute  stage  has  passed,  and  in  chronic  cases,  use  iodine 
externally  and  per  vaginam,  blisters  and  glycerine  vaginal  tampons. 
A  wet  towel,  covered  by  a  dry  one  or  a  protective,  worn  about  the 
pelvis  at  night,  is  sometimes  of  value  in  chronic  peritonitis.  Look 
after  the  general  health  by  attention  to  fresh  air,  administering 
tonics,  and  regulating  the  bowels. 


Pelvic  Cellulitis. 

What  are  the  principal  situations  of  the  cellular  tissue  in  the 
pelvis  ? 

1.  Between  the  abdominal  wall  and  peritoneum,  behind  the  pubes. 

2.  In  front  of  and  behind  the  cervix. 

3.  In  the  broad  ligaments. 

4.  In  the  utero-sacral  ligaments. 


88  ESSENTIALS  OF  GYNECOLOGY. 

What  is  the  etiology  of  pelvic  cellulitis  ? 

The  etiology  of  pelvic  cellulitis  may  almost  invariably  be  summed 
up  in  two  words — traumatism  and  sepsis  ;  the  traumatism  being, 
usually,  labor,  abortion,  or  operations  on  the  cervix. 

Pelvic  cellulitis  was  formerly  considered  very  common,  but  in  the 
light  of  recent  experience,  gained  by  laparotomies,  the  ' '  masses, ' ' 
"thickenings,"  etc.,  are  most  often  found  to  be  salpingitis  and 
peritonitis. 

In  other  words,  pelvic  cellulitis,  although  it  does  exist,  is  com- 
paratively infrequent. 

What  is  the  pathology  ? 

There  is  an  exudation  of  serum,  fibrin  and  white  cells  ;  this  may 
resolve,  it  may  form  new  connective  tissue,  cicatricial  tissue,  or  it 
may,  and  often  does,  suppurate.  If  suppuration  occurs,  the  pus 
may  point  above  the  pubes  ;  this  is  especially  common  in  puerperal 
cases.  It  frequently  ruptures  into  the  vagina,  bladder  or  rectum, 
sometimes  into  the  uterus  ;  it  occasionally  makes  its  way  through 
the  sciatic  or  obturator  foramen  ;  rarely,  it  ruptures  into  the  peri- 
toneal cavity. 

What  are  the  symptoms  of  pelvic  cellulitis  ? 

The  disease  is  usually  ushered  in  by  a  rigor,  which  is  often  marked ; 
the  temperature  rises,  103°-105°  ;  the  pulse  is  full  and  rapid  ;  the 
pain  is  not  very  acute  ;  nausea  is  occasionally  present ;  vomiting  is 
usually  absent,  unless  peritonitis  is  a  complication.  If  pus  forms, 
septic  symptoms  become  pronounced.  There  is  often  irritability  of 
bladder  and  rectum. 

Chronic  cases  may  present  few  symptoms  save  a  feeling  of  weight 
in  the  pelvis,  irritability  of  bladder  and  rectum,  and  menorrhagia. 

What  are  the  physical  signs  ? 

Usually,  there  is  a  tense,  elastic  tumor  bulging  into  the  vagina, 
most  commonly  on  the  left  side,  pushing  uterus  over  to  the  right ; 
it  is  sensitive,  but  not  acutely  so.  Sometimes  the  inflammatory 
process  involves  nearly  all  the  connective  tissue  of  the  pelvis,  and  the 
exudation  can  be  felt  in  the  iliac  fossae  and  above  the  pubes.  When 
1  his  forms  you  have  the  physical  signs  of  an  abscess — tenderness, 
fluctuation,  etc. 


PELVIC  CELLULITIS.  8& 

From  what  should  you  differentiate  pelvic  cellulitis  ? 

From —  a.  Pelvic  peritonitis. 

b.  Pelvic  haematocele. 

c.  Fibroid  tumor  of  uterus. 

d.  Impaction  of  faeces. 

e.  Ovarian  tumor. 
/  Salpingitis. 

How  would  you  differentiate  pelvic  cellulitis  from  pelvic 
peritonitis  ? 
In  many  cases  it  is  almost  impossible  to  differentiate  the  two  ; 
they  frequently  complicate  each  other.  The  chief  points  of  difference 
are  these  :  Pelvic  cellulitis  almost  never  occurs  except  after  labor, 
abortion,  or  operation  on  the  cervix  ;  pelvic  peritonitis  may  arise 
from  any  cause  of  inflammation  of  the  uterus  or  its  adnexa,  which 
may  extend  to  the  peritoneum.  Pain  and  tenderness,  as  a  rule, 
are  less  marked  in  cellulitis  than  in  peritonitis.  Cellulitis  is  more 
apt  to  bulge  into  the  vagina  than  is  peritonitis.  Cellulitic  deposits 
are  more  apt  to  suppurate  than  are  peritonitic.  Yomiting  is  less 
frequent  in  cellulitis  than  in  peritonitis. 

How  would  you  differentiate  pelvic  cellulitis  from  pelvic 
hematocele  ? 

Chiefly  by  the  history  of  an  hematocele,  i.  e. ,  sudden  sharp  pain, 
pallor,  faintness,  and  the  physical  signs  of  a  collection  of  fluid  which 
afterward  coagulates  and  hardens.  The  above  symptoms  of  shock 
and  hemorrhage  are  wanting  in  cellulitis. 

How  would  you  differentiate  cellulitic  or  peritonitic  deposits 
from  fibroids  of  the  uterus  ? 

Cellulitic  or  peritonitic  deposits    vs.  Fibroid  tumors. 

History  of  acute  inflammation.        Slow  growth. 

Pain  and  tenderness.  Insensitive. 

Less  plainly  outlined.  Outlines  more  distinct. 

Less  intimately  connected  with      Closely     connected     with     the 

the  uterus.  uterus. 

Perhaps  menorrhagia  during  the      Usually  menorrhagia,   gradually 

acute    stage,    then    irregular         increasing  till  the  menopause. 

menstruation. 


'.")  ESSENTIALS   OP  GYNECOLOGY. 

How  would  you  differentiate  impaction  of  faeces  from  pelvic 
peritonitis  or  cellulitis  ? 

In  impaction  of  faeces,  the  mass  is  sausage-shaped,  has  a  doughy 
feel,  and  is  less  closely  connected  with  the  uterus  than  an  exudation 
of  peritonitis  or  cellulitis  ;  it  is  not  as  tender  on  pressure,  and  gives 
no  history  of  acute  inflammation.  The  diagnosis  is  made  certain  by 
clearing  out  the  rectum. 

How  would  you  differentiate  a  small  ovarian  tumor  from 
pelvic  peritonitis  or  cellulitis  ? 

There  are  no  signs  of  acute  inflammation  as  in  cellulitis  or  perito- 
nitis ;  the  ovarian  cyst  is  usually  fluctuating  ;  its  multilocular  char- 
acter can  sometimes  be  felt.  The  menstrual  disturbances  common 
in  peritonitis  and  cellulitis  are  usually  absent  in  cases  of  ovarian  cysts ; 
an  ovarian  cyst  gradually  increases  in  size. 

How  would  you  differentiate  pelvic  cellulitis  from  salpin- 
gitis ? 

By  a  careful  bimanual,  in  a  case  of  salpingitis,  you  can  generally 
map  out  an  enlarged,  tortuous  tube,  usually  distended,  extending 
from  the  side  of  the  uterus  to  the  region  of  the  ovary  ;  if  distended 
with  fluid,  you  may  detect  fluctuation.  It  does  not  bulge  into  the 
vagina  as  does  cellulitis. 

The  history  of  the  case  is  of  value  in  the  diagnosis. 

What  is  the  treatment  of  pelvic  cellulitis  ? 

1.  Prophylactic  : — 

Strict  cleanliness  and  antiseptic  precautions  during  labor,  abortion, 
operations,  etc. 

2.  Abortive  : — 

Put  patient  to  bed,  give  a  diaphoretic,  as  Dover's  powder,  and 
administer  prolonged  hot-water  vaginal  douches. 

3.  When  exudation  has  occurred  : — 

Apply  hot  poultices  to  the  abdomen,  administer  hot-water  vaginal 
douches,  move  bowels,  and  attend  to  the  general  health. 

4.  When  the  cellulitis  has  become  chronic  : — 

Apply  counter-irritation  externally  by  means  of  iodine  or  blisters  ; 
per  vaginam,  employ  hot-water  douches,  applications  of  iodine  to 
the  fornices,  also  glycerine  tampons. 


PELVIC   HEMATOCELE  AND   HEMATOMA.  91 

5.   When  the  exudation  suppurates  : — 

If  the  abscess  points,  incise  under  antiseptic  precautions  and  drain. 
if  it  does  not  point,  it  is  better  to  do  an  exploratory  laparotomy  in 
order  to  remove  the  abscess  sac  en  masse,  or,  if  this  is  not  practi- 
cable, to  determine  the  best  place  for  opening  into  it  from  the  vagina, 


Pelvic  Haematocele  and  Haematoma. 

Define,  and  give  the  pathology. 

Pelvic  haematocele  is  an  effusion  of  blood  into  the  cavity  of  the 
pelvic  peritoneum,  enclosed  by  anatomical  structures  or  inflammatoiy 
adhesions.     (Hart  and  Barbour.) 

Pelvic  haematoma  is  an  effusion  of  blood  into  the  connective  tissue 
of  the  pelvis  beneath  the  peritoneum,  usually  between  the  folds  of 
the  broad  ligaments. 

In  a  pelvic  haematocele,  the  effusion  is  usually  into  the  pouch  of 
Douglas  ;  if  this  is  closed  by  adhesions,  or  if  the  effusion  is  veiy 
large,  the  blood  majT  flow  over  into  the  utero-vesical  pouch.  The 
former  condition  gives  rise  to  the  name  retro-uterine,  the  latter  to 
ante-uterine  haematocele.  The  blood  is  at  first  fluid  ;  it  then  coagu- 
lates. It  may  remain  unchanged  for  a  long  time  ;  if  small,  it  is 
usually  absorbed.  It  may  suppurate  and  break  through  into  the 
rectum  or  vagina,  rarely  into  the  bladder  or  peritoneum. 

What  is  the  etiology  ? 

A.  Predisposing  causes  : — 

Active  menstrual  life,  25-35. 

Extra-uterine  gestation. 

Frequent  child-bearing. 

Varicose  condition  of  veins  of  broad  ligament. 

Disease  of  tubes  or  ovaries. 

Previous  pelvic  peritonitis,  with  adhesions. 

Atresia  of  genital  tract. 

Haemophilia, 

Poor  surroundings. 

Low  state  of  the  system. 

Anything  causing  congestion  of  the  pelvic  viscera. 


92  ESSENTIALS  OF  GYNECOLOGY. 

B.  Exciting  causes  : — 

Traumatism,  blows,  falls,  etc. 

Violent  coitus  during  menstruation. 

Sudden  arrest  of  menstruation  by  exposure  to  cold. 

Labor. 
Some   authorities  now  think  that  most  of  the  cases  of  pelvi  ■ 
haematocele  are  due  to  extra-uterine  pregnancy. 

What  are  the  symptoms  of  pelvic  haematocele  ? 

A  sudden  sharp  pain,  and  symptoms  of  shock  and  hemorrhage. 
The  face  becomes  pallid,  the  expression  anxious  ;  the  pulse  is  rapid 
and  feeble ;  surface  covered  with  a  cold  perspiration ;  perhaps  nausea 
and  vomiting.  Later,  if  the  patient  survive,  we  have  symptoms  of 
peritonitis  and  of  pressure,  either  from  the  effusion  or  the  displaced 
uterus.  The  pain  and  tenderness  continue  for  several  days  ;  there  is 
usually  painful  defecation  and  dysuria ;  sometimes  menorrhagia  is 
present.  In  a  few  days,  if  suppuration  does  not  occur,  the  effusion 
diminishes  in  size  and  the  symptoms  abate.  If  suppuration  occurs, 
septic  symptoms  appear. 

The  above  are  the  symptoms  of  a  well-marked  case ;  where  the 
effusion  is  small  the  symptoms  may  be  much  less  severe. 

How  do  the  symptoms  of  pelvic  haematoma  compare  with 
those  of  pelvic  haematocele  ? 

In  pelvic  haematoma  there  is,  as  a  rule,  less  pain  and  less  shock. 
If  the  effusion  is  large,  however,  there  may  be  the  symptoms  of 
shock  and  hemorrhage. 

What  are  the  physical  signs  of  pelvic  haematocele  ? 

A  tumor,  usually  behind  the  uterus,  pushing  the  latter  forward  ; 
it  is  tense,  elastic,  tender  ;  at  first  soft,  later  smaller  and  harder.  If 
suppuration  occurs,  it  again  becomes  soft  and  fluctuating.  If  the 
abscess  is  to  break  into  the  rectum,  this  event  is  usually  preceded  by 
a  mucous  discharge  from  the  latter. 

What  are  the  physical  signs  of  pelvic  haematoma  ? 

A  small,  tense,  elastic  tumor  at  the  side  of  the  uterus,  not  as 
tender  as  an  haematocele. 

What  is  the  prognosis  of  pelvic  haematocele  ? 

The  prognosis  is  grave  ;  they  may  die  at  once  from  shock  and 


PELVIC   HEMATOCELE  AND   HEMATOMA.  9d 

hemorrhage,-  or  later  from  peritonitis  or  sepsis.  If  the  effusion  is 
small  and  well  encapsulated,  recoveiy  often  occurs.  If  the  hsemato- 
cele  results  from  the  rupture  of  an  extra  -uterine  fruit  sac  of  any  con- 
siderable size,  the  case,  without  operation,  is  usually  fatal. 

What  is  the  prognosis  of  pelvic  hsematoma  ? 

Usually  good.     If  the  effusion  suppurates,  the  prognosis  is  less 
favorable. 


How  would  you  differentiate  pelvic  hematocele  from  acute 
pelvic  peritonitis  ? 


Pelvic  hematocele 

History  of  sudden,  sharp  pain, 
with  symptoms  of  shock  and 
hemorrhage. 

.Absence  of  acute  inflammation 
at  first. 

Uterus  usually  displaced  for- 
ward. 


vs.  Acute  pelvic  peritonitis. 

Less  sudden  in  onset ;  symptoms 
of  shock  and  hemorrhage 
wanting. 

Symptoms  of  acute  inflammation 
at  first. 

Uterus  fixed,  not  markedly  dis- 
placed. 


How  would  you  differentiate  pelvic  hematocele  from  a  fibroid 
tumor  of  the  uterus  ? 


Pelvic  hcematocele 

History  of  sudden,  sharp  pain 
and  symptoms  of  shock  and 
hemorrhage. 

Soon  followed  by  signs  of  in- 
flammation. 

Less  intimately  connected  with 
the  uterus. 

Sensitive  to  pressure. 

Density  less. 


vs.  Fibroid  tumor. 

Of  slow  growth ;  symptoms 
gradually  developed. 

Absence  of  signs  of  inflamma- 
tion. 

More  intimately  connected  with 
the  uterus  ;  moves  with  it. 

Insensitive  to  pressure. 

Density  greater. 


94  ESSENTIALS   OF  GYNECOLOGY. 

How  would  you  differentiate  pelvic  hematocele  from  a  retro- 
flexed  or  retroverted  uterus  ? 

Pelvic  hcematocele  vs.  Retroflexed  or  retroverted  uterus. 

Acute  history  of  pain,  shock  and      Usually  a  long  history. 

hemorrhage. 
Fundus  of  uterus   usually  lies      Fundus    backward ;     absent    in 

forward.  front. 

Sensitive  to  pressure.  Less  sensitive,  unless  surrounded 

by  peritonitis. 

How  would  you  differentiate  pelvic  haematocele  from  an 
ovarian  cyst  ? 

Pelvic  hcematocele  vs.  Ovarian  cyst. 

Acute  histoiy  of  pain,  shock  and      History  of  slow  growth,  with  few 

hemorrhage.  general  symptoms. 

More  sensitive  to  pressure.  Less  sensitive  to  pressure. 

First  elastic  and  soft,  then  hard.       Usually  fluctuating  throughout. 

How  would  you  differentiate  pelvic  haematocele  from  im- 
pacted faeces  ? 

By  the  histoiy,  rectal  examination,  and  thorough  emptying  of  the 
rectum. 

How  would  you  differentiate  pelvic  haematocele  from  retro- 
uterine carcinoma  ? 

Pelvic  hematocele  vs.       Retro-uterine  carcinoma. 

Acute  histoiy  of  pain,  shock  and      Histoiy  of  a  chronic  disease. 

hemorrhage. 
Uterus  usually  pushed  forward.       Uterus  but  little  displaced. 

How  would  you  differentiate  pelvic  haematoma  from  pelvic 
cellulitis  ? 

Pelvic  hematoma              vs.  Pelvic  cellulitis. 

Histoiy  of  sudden,  sharp  pain,  Histoiy  of   labor,    abortion,    or 

perhaps   symptoms  of   shock  operation  on  the  cervix. 

and  hemorrhage. 

Signs  of  acute  inflammation  ab-  Signs    of    acute     inflammation 

Miit  at  first.  from  the  first. 

Less  sensitive.  More  sensitive. 


PELVIC  HEMATOCELE  AND   HEMATOMA.  95 

What  is  the  treatment  of  pelvic  hematocele  ? 

The  indications  are  : — 

1.  To  arrest  hemorrhage  and  relieve  the  shock. 

2.  To  treat  inflammatory  complications  and  cause  absorption  of  the 
exudation. 

3.  To  avoid  sepsis. 

Keep  the  patient  perfectly  quiet ;  it  is  well  to  give  a  small  hypo- 
dermic of  morphine  to  quiet  alarm  and  mitigate  the  shock.  Some 
recommend  the  application  of  ice  to  the  vagina  and  abdomen.  Give 
light  diet. 

Later,  apply  heat  externally  and  internally,  by  hot  poultices  to 
the  abdomen  and  hot-water  douches  to  the  vagina  ;  blisters  may  be 
of  value. 

If  the  hasniatocele  is  the  result  of  the  rupture  of  an  extra-uterine 
fruit  sac,  open  the  abdomen,  check  hemorrhage  (by  clamping,  and 
later,  ligaturing  broad  ligament),  cleanse  the  abdominal  cavity  and 
drain  it. 

If  the  effusion  of  blood  suppurates,  free  drainage  is  desired.  This 
is  usually  best  accomplished  by  opening  the  abdomen,  and  if  the  pus 
sac  cannot  be  removed,  drain  through  the  vagina,  with  the  aid  of 
sight  and  touch  given  by  the  abdominal  opening.  By  this  means 
one  can  puncture  where  sac  is  adherent  to  vagina  without  going 
through  healthy  peritoneum  or  intestine. 

What  is  the  treatment  of  pelvic  hematoma  ? 

The  indications  for  treatment  are  the  same  as  for  pelvic  haemato- 
cele  :  Quiet,  cold,  followed  later  by  heat  externally  and  internally  ; 
blisters.  If  suppuration  occurs,  drain  through  the  vagina.  It  is 
often  advisable  to  open  the  abdomen  to  determine  the  best  situation 
to  establish  drainage  through  the  vagina. 


96  ESSENTIALS   OF  GYNAECOLOGY. 


MENSTRUATION. 

Define. 

Menstruation  is  a  periodical  series  of  phenomena,  the  most  marked 
of  which  is  a  discharge  of  blood  from  the  uterine  mucous  membrane, 
with  a  shedding  of  its  superficial  layers,  beginning,  on  an  average,  in 
this  country,  at  fourteen,  and  recurring  monthly  till  forty-four.  The 
relation  of  menstruation  to  ovulation  is  still  unsettled  ;  Lawson  Tait 
claiming  that  the  Fallopian  tubes  have  more  influence  on  menstrua- 
tion than  have  the  ovaries. 

Describe  the  factors  which  influence  the  onset  of  menstrua- 
tion ;  what  is  the  average  frequency  and  duration  of 
each  period  ? 

In  temperate  climates,  menstruation  usually  appears  at  13-15 
years  ;  it  is  earlier  in  warmer  climates,  later  in  cooler  ;  it  appears  in 
girls  who  live  an  indoor,  city  life,  earlier  than  in  the  country.  The 
periods  normally  appear  every  28  days,  but  in  this  there  are  great 
variations ;  some  women  in  perfect  health  menstruate  every  3  weeks, 
some  only  every  5  weeks. 

The  average  duration  of  each  period  is  3-4  days,  but  this  varies 
between  2  and  8.  The  discharge  of  blood  is  usually  slight  at  first, 
reaches  maximum  on  the  second  or  third  day,  then  gradually  dimin- 
ishes. 

Disorders  of  Menstruation. 

Amenorrhea. 

Define. 

Amenorrhoea  is  the  absence  of  menstruation  between  puberty  and 
the  menopause.  It  is  the  normal  condition  during  pregnancy  and 
lactation.     It  may  be  divided  into  : — 

a.  Emansio  mensium — 

Where  menstruation  has  never  appeared. 

b.  Suppresio  mensium — 

Where  menstruation  has  appeared,  but  fails  to  reappear, 


MENSTRUATION — AMENORRHEA.  97 

What  i#  the  etiology  of  amenorrhoea  ? 

The  most  frequent  cause  is  anaemia,  especially  that  form  called 
chlorosis.  Other  causes  are  phthisis,  or  other  debilitating  diseases  ; 
acute  diseases  at  puberty ;  non-development  of  the  generative  organs ; 
atrophy  of  the  generative  organs ;  increasing  obesity ;  removal  of 
ovaries  and  tubes  by  operation. 

What  are  the  symptoms  ? 

Amenorrhoea  is  itself  more  a  symptom  than  a  disease,  and  the 
symptoms  which  usually  accompany  amenorrhoea  are  those  of  the 
disease  which  causes  it — most  frequently  anaemia  or  phthisis.  Thus, 
from  anaemia  we  have  : — 

Pallor. 

Dyspnoea  and  palpitation  of  the  heart  on  exertion. 

DejDraved  appetite. 

Constipation. 

Headache. 

(Edema. 

Murmur  at  the  base  of  the  heart. 

Neuralgic  pains. 

Hysteria. 
From  phthisis  we  get  the  regular  symptoms  of  cough,  emaciation 
and  night  sweats. 

What  is  the  prognosis  ? 

When  associated  with  simple  anaemia  the  prognosis  is  good. 
When  due  to  non-development  of  the  generative  organs  the  amen- 
orrhoea usually  continues.  When  associated  with  phthisis  or  other 
wasting  disease,  the  prognosis  is  that  of  the  disease. 

What  is  the  treatment  of  amenorrhoea  ? 

a.  When  due  to  anaemia  : — 

Some  form  of  iron,  as  Blaud's  pills;  oxygen;  nourishing  food; 
fresh  air ;  regulation  of  the  bowels,  and  attention  to  the  mode  of 
life.  Permanganate  of  potash  and  the  black  oxide  of  manganese 
are  recommended,  but  their  usefulness  is  doubted  by  many. 

b.  When  due  to  imperfect,  or  non-development  of  the  generative 
organs  : — 

Determine,  under  anaesthesia,  whether  ovaries  are  present  or  not ; 
if  absent,  do  not  attempt  to  induce  menstruation.    If  the  ovaries  are 
7 


y»  ESSENTIALS   OF  GYNECOLOGY. 

present,  besides  attention  to  the  general  health,  the  following  methods 
may  be  employed  : — 

Hot  water  vaginal  douches  ; 

Boro-glyceride  tampons  ; 

Electricity  to  uterus  and  over  ovaries. 
c.  When  associated  with  phthisis,  or  other  wasting  disease,  the 
treatment  is  that  of  the  associated  disease. 

In  cases  of  acute  suppressio-mensium,  due  to  exposure  to  cold, 
etc. ,  hot  mustard  foot  baths,  hot  applications  to  the  pelvic  region 
and  diaphoretics  internally,  may  be  used  with  safety  and  advantage. 

Vicarious  Menstruation. 

Describe. 

Vicarious  menstruation  is  a  periodical  discharge  of  blood  from 
some  part  of  the  body  other  than  the  interior  of  the  uterus.  It  may 
occur  with  either  amenorrhoea  or  scanty  menstruation ;  it  usually 
appears  at  about  the  time  of  the  regular  flow.  It  may  come  from 
almost  any  mucous  membrane  :  from  the  nose,  mouth,  breast,  etc. ; 
it  may  also  come  from  an  open  sore  ;  it  is  usually  due  to  a  watery 
condition  of  the  blood  and  a  poor  condition  of  the  blood  vessels. 
Direct  treatment  is  usually  not  required. 

Menorrhagia  and  Metrorrhagia. 

Define. 

Menorrhagia  is  a  prolonged  or  excessive  menstrual  flow. 

Metrorrhagia  is  ' '  uterine  hemorrhage  occurring  independently  of 
the  menses. ' ' 

What  is  the  etiology? 

Menorrhagia  and  metrorrhagia  may  be  produced  by  causes  acting 
at  a  distance,  or  local,  in  or  about  the  uterus  itself.  Acting  at  a 
distance  are  : — 

1.  Obstructed  general  circulation  from  disease  of  heart,  lungs  or 
liver. 

2.  Low  condition  of  blood  and  vessels  in  certain  wasting  diseases. 
Acting  about  the  uterus  are  : — 

1.  Inflammation  of  the  pelvic  peritoneum  ; 

2.  Disease  of  tubes  or  ovaries  ; 

3.  Tumors, 


MENSTRUATION — DYSMENORRHEA.  99 

The  most  common  causes  are  situated  in  the  uterus  itself,  and 
among  them  are  the  following  : — 

1 .  Subinvolution  of  the  uterus  ; 

2.  Retained  secundines  ; 

3.  Submucous,  or  interstitial  fibroids  ; 

4.  Polypi ; 

5.  Carcinoma ; 

6.  Fungous  granulations  of  the  endometrium. 
The  last  is  the  most  common  cause  of  all. 

What  is  the  treatment  of  menorrhagia  and  metrorrhagia  ? 

When  due  to  causes  acting  outside  of  the  uterus,  the  treatment  is 
that  of  these  causes ;  at  the  same  time,  there  will  often  be  found 
fungous  granulations  of  the  endometrium  which  magnify  the  influ- 
ence of  the  distant  causes  ;  these  fungosities  need  to  be  removed  by 
the  curette,  under  antiseptic  precautions,  and  iodine,  or  carbolic 
acid,  or  a  mixture  of  the  two,  applied  to  the  endometrium ;  it  is 
then  advisable  to  administer  the  fluid  extracts  of  hydrastis  cana- 
densis and  ergot.  Disease  of  the  pelvic  peritoneum,  tubes  or  ovaries 
requires  its  own  treatment.  Fibroids  may  demand  removal  of  ova- 
ries and  tubes.  Polypi  require  removal.  Carcinoma  needs  its  own 
treatment.     Fungous  granulations  demand  curetting  as  above. 

Dysmenorrhea. 

Define. 

' '  Dysmenorrhoea  may  be  defined  as  the  occurrence  of  pain  jusi 
before,  during  or  after  the  menstrual  period ' '  (Hart  and  Barbour). 

What  are  the  varieties  of  dysmenorrhoea  ? 

The  following  varieties  are  mentioned,  but  seldom  distinctly 
differentiated  : — 

1 .  Obstructive  ; 

2.  Congestive ; 

3.  Neuralgic ; 

4.  Ovarian  ; 

5.  Membranous. 


100  essentials  of  gynaecology. 

Obstructive  Dysmenorrhea. 

What  is  the  etiology  ? 

Both  the  etiology  and  pathology  of  the  different  varieties  of 
dysmenorrhoea  are  still  far  from  settled,  hut  the  conditions  usually 
associated  with  obstructive  dysmenorrhoea  are  : — 

a.  Flexions  of  the  uterus  ; 

b.  Stenosis  of  os  externum,  os  internum,  or  the  whole  cervical 

canal ;  % 

c.  Polypi ; 

d.  Fibroids  distorting  uterine  canal ; 

e.  Long,  conical  cervix  ; 

/.    Spasmodic  contraction  of  os  internum. 

What  are  the  symptoms  ? 

Intermittent,  cramp-like  pains,  accompanying  the  expulsion  of 
blood  clots  which  have  formed  above  the  obstruction ;  this  expulsion 
is  followed  by  relief.  A  sound  passed  between  the  periods  usually 
shows  hyperesthesia  of  the  internal  os. 

What  is  the  treatment  ? 

Mechanical  dilatation  of  the  cervical  canal  by  one  of  the  dilators 
of  the  glove-stretcher  variety,  and  the  maintenance  of  the  patency 
by  the  occasional  passage  of  graduated  sounds  for  a  few  weeks,  or, 
as  some  recommend,  by  the  introduction  of  an  intra-uterine  stem  so 
arranged  as  to  drain  ;  this  may  be  of  hard  rubber,  or  of  wire,  as  that 
of  Outerbridge. 

It  is  often  wise  to  touch  the  internal  os  after  dilatation  with  car- 
bolic acid,  or  iodized  phenol. 

The  intra-uterine  stem  should  only  be  used  while  the  patient  is  iu 
bed, 

Congestive  Dysmenorrhea. 

What  is  the  etiology  ? 

"Congestive  dysmenorrhoea  depends  upon  an  advance  of  the 
menstrual  congestion  beyond  the  physiological  limits  "  (Reeve). 

The  conditions  associated  with  congestive  dysmenorrhoea  arc  the 
following : — 

a.  Exposure  to  cold  ; 

b.  Defective  general  circulation  ; 


MENSTRUATION — DYSMENORRHEA.  101 

c.  Metritis'; 

d.  Endometritis ; 

e.  Displacements  of  the  uterus  ; 
/    Pelvic  tumors ; 

g.  Pelvic  peritonitis. 

What  are  the  symptoms  ? 

Between  the  periods  there  are  usually  symptoms  of  pelvic  trouble, 
or  defective  general  circulation. 

Just  before  the  flow  begins,  there  appear  feelings  of  weight  and 
heat  in  back  and  pelvis,  headache,  flushing  of  the  face,  and  some 
rise  of  temperature  ;  the  pulse  is  rapid.  The  symptoms  are  usually 
relieved  by  a  free  flow. 

What  is  the  treatment  ? 

a. .  During  the  attack — 

1.  Hot  mustard  foot-baths ; 

2.  Hot  sitz-baths ; 

3.  Diaphoretics ; 

4.  Hot  pelvic  applications. 
b.  During  the  intermenstrual  periods — 

1.  Seek  to  remove  the  cause  ; 

2.  Scarify  cervix  occasionally ; 

3.  Employ  glycerine  tampons  ; 

4.  Avoid  excessive  coitus  and  exertion. 
Just  before  the  flow  begins,  use  hot -water  vaginal  douches. 

Neuralgic  Dysmenorrhea. 

What  is  the  etiology  ? 

This  frequently  occurs  in  combination  with  some  of  the  other 
forms  of  dysmenorrhcea,  especially  the  congestive  ;  it  is  most  often 
associated  with  an  indolent,  indoor  life,  anaemia,  malnutrition, 
chronic  malarial  disease  or  hysteria.  Sometimes  no  cause  can  be 
assigned. 

What  are  the  symptoms  ? 

Pain,  sometimes  referred  to  uterus,  sometimes  to  ovaries,  some- 
times elsewhere  ;  it  changes  its  situation  ;  is  often  shooting  in  char- 
acter ;  usually  begins  a  little  before  the  flow  ;  is  sometimes  relieved 


102  ESSENTIALS  OF  GYNECOLOGY. 

by  a  free  flow.  Between  the  periods,  no  pathological  changes  can 
be  detected  in  the  pelvic  organs,  but  patient  suffers  from  neuralgia 
elsewhere — facial,  intercostal,  etc. 

What  is  the  treatment? 

Attention  to  the  mode  of  life;  fresh  air  ;  exercise  ;  tonics,  espe- 
cially iron,  arsenic  and  quinine ;  at  the  onset  of  the  pelvic  pains 
employ  hot  sitz-baths  and  hot-water  vaginal  douches. 

Ovarian  Dysmenorrhea. 

What  is  the  etiology  ? 

This  is  applied  to  a  class  of  cases  associated  with  disease  of  the 
ovaries,  but  the  etiology  is  far  from  settled,  and  the  class  not  distinct. 

What  are  the  symptoms  ? 

Between  the  periods  there  is  pain  and  tenderness  over  the  region 
of  the  ovary,  increased  by  exercise,  defecation  and  coitus ;  these 
symptoms  are  increased  at  the  menstrual  periods. 


Membranous  Dysmenorrhea. 
Describe. 

Membranous  dysmenorrhoea  is  characterized  by  the  expulsion  at 
the  menstrual  periods  of  organized  membranes  either  as  a  whole  or 
in  pieces. ' '  (Reeve. ) 

What  is  the  etiology  and  pathology  ? 

These  are  both  matters  of  dispute,  but  we  usually  find  in  these 
cases  chronic  endometritis  and  poor  general  health.  The  inner 
surface  of  the  membrane  is  smooth  and  shows  the  openings  of  the 
utricular  glands ;  its  external  surface  is  rough  and  shaggy  (see  Fig. 
12). 

According  to  Hart  and  Barbour,  "  It  is  of  the  greatest  importance 
to  remember  that  it  is  not  a  product  of  conception,  and  should  not 
De  mistaken  for  an  early  abortion. ' '  It  is  composed  of  the  super- 
ficial layer  of  the  endometrium,  with  increased  connective  tissue ; 
blood  accumulates  under  it  and  dissects  it  off. 

What  are  the  symptoms  ? 

Severe  colicky  pain,  usually  recurring  at  each  period  ;  the  flow  is 


MENSTRUATION — DYSMENORRHEA. 


103 


often  intermittent ;  thus  the  symptoms  resemble  those  of  obstructive 
dysinenorrhoea.     The  course  is  usually  protracted. 

How  would  you  differentiate  membranous  dysmenorrhea 
from  an  early  abortion  ? 

By  the  absence  of  chorionic  villi  and  by  the  repeated  occurrence 

Fig.  12. 


Sketch  of  a  Dysmenorrhceal  Membrane  as  seen  under  Water  (Sir  J.  Y.  Simpson). 


What  is  the  treatment  ? 

a.  Between  the  periods — 

Dilate  the  cervix,  curette  the  uterine  canal,  and  apply  to  the 
endometrium  iodized  phenol,  pure  carbolic,  or  tincture  of  iodine. 
I).  During  the  menstrual  period — 
Use  hot  baths,  hot  applications  to  the  pelvis,  and  diaphoretics. 


104  ESSENTIALS   OP  GYNAECOLOGY. 

Malformations  of  the  Vagina. 

What  are  the  important  varieties  ? 

a.  Atresia  vaginae ; 

b.  Double  vagina ; 

c.  Absence  of  vagina. 

Atresia  Vaginae. 

Give  the  varieties  and  etiology. 

Atresia  of  the  vagina  may  be  either  at  the  hymen,  forming  atresia 
hymenalis,  or  higher  up  in  the  vagina,  forming  atresia  vaginalis. 

Etiology. — Atresia  hymenalis  is  usually  congenital,  from  mal- 
development.  Atresia  vaginalis  is  either  congenital,  or  may  be 
acquired  from  cicatrization  following — 

a.  Sloughing  incident  to  parturition  ; 

b.  Adhesive  vaginitis ; 

c.  Traumatism ; 

d.  Caustics. 

What  are  the  symptoms  of  atresia  vaginae  ? 

They  are  dependent  on  the  accumulation  of  the  menstrual  blood, 
hence  in  congenital  cases  they  are  absent  till  puberty.  The  subjective 
symptoms  of  menstruation  come  on,  but  there  is  no  appearance  of 
blood ;  at  the  next  period  the  subjective  symptoms  are  repeated. 
The  periods  then  usually  come  more  frequently,  and  soon  a  tumor 
forms.  If  the  atresia  is  at  the  hymen,  the  latter  bulges,  and  the 
vagina  is  distended  with  blood,  forming  a  haemato-colpos. 

In  atresia  hymenalis  the  cervix  is  usually  not  dilated  ;  in  atresia 
vaginalis  the  dilatation  may  extend  to  the  uterus  and  tubes. 

If  the  atresia  is  acquired,  of  course  there  will  be  no  symptoms  till 
the  menstrual  blood  is  retained. 

What  are  the  results  of  atresia  hymenalis  if  unrelieved  by 
operation  ? 

If  the  hymen  is  thin,  it  may  rupture  ;  if  thick,  the  vagina  may 
rupture  ;  after  rupture,  septicaemia  may  occur. 

What  are  the  results  of  atresia  vaginalis  ? 
The  vagina  may  rupture. 


MALFORMATIONS   OF  THE  VAGINA.  105 

The  uterus  and  tubes  may  become  distended,  forming  haeniato-' 
metra  or  haeniato-salpinx,  and  may  rupture. 
The  atresia  may  rapture. 
After  rapture,  septicaemia  may  occur. 

Where  else  in  the  genital  tract  than  in  the  vagina  may 
atresia  occur  ?    Give  the  etiology  and  symptoms. 

Atresia  may  occur  at  the  cervix. 

Atresia  of  the  cervix  may  be  congenital,  or  acquired  from  cicatri- 
zation following  parturition,  the  use  of  caustics,  or  from  a  too  close 
trachelorrhaphy.  Symptoms  appear  when  the  menstrual  blood  ac- 
cumulates behind  the  atresia,  and  resemble  those  of  atresia  vaginae. 
The  amenorrhoea  and  enlargement  of  the  uterus  may  make  one 
suspect  pregnancy. 

What  are  the  results  of  atresia  of  the  cervix  if  unrelieved  by 
operation  ? 

If  it  is  present  during  menstrual  life,  the  uterus  and  tubes  become 
distended,  and  are  liable  to  rapture,  with  the  danger  of  peritonitis 
and  death.  If  it  occurs  for  the  first  time  after  the  menopause,  it 
may  cause  little  trouble,  or  the  atresia  may  rapture. 

What  is  the  character  of  the  retained  fluid  ? 

During  menstrual  life  the  blood  is  of  a  brownish,  chocolate  color ; 
it  is  grumous  and  treacle-like  in  consistency,  kept  from  clotting  by 
the  mucus. 

After  the  menopause,  the  retained  fluid  is  honey-like. 

What  is  the  treatment  of  atresia  of  the  genital  tract  with 
retention  of  the  menstrual  blood  ? 

Aspirate  slowly ;  under  strict  antiseptics,  incise  the  obstruction, 
and  maintain  the  opening  by  a  glass  plug. 

What  are  the  dangers  of  rapid  evacuation  of  a  haemato- 
metra  ? 

The  tubes  are  probably  distended,  and  have  formed  adhesions ; 
the  rapid  collapse  of  the  uterus  would  tend  to  tear  the  tubes  from 
their  adhesions,  with  the  danger  of  rupture  of  the  tubes,  and  perito- 
nitis. 


106 


ESSENTIALS  OF  GYNAECOLOGY. 


Malformations  of  the  Uterus. 

What  are  the  principal  varieties  ? 

1 .  Rudimentary  uterus ; 

2.  Uterus  bipartitus ; 

3.  Uterus  unicornis ; 

4.  Uterus  bicornis ; 

5.  Uterus  didelphys ; 

6.  Uterus  septus ; 

7.  Infantile  uterus ; 

8.  Congenital  atrophy  of  the  uterus  ; 

9.  Complete  absence  of  the  uterus,  very  rare. 

Fig.  13. 


Rudimentary  Uterus  (Veit).     Sa,  sacrum;    U,  solid  rudiment  of  uterus;  h,  rudi- 
mentary horn;  B,  bladder;  0,  ovary;  T,  Fallopian  tube;  r  round  ligament. 


Describe  the  rudimentary  uterus. 

In  this  case  (see  Fig.  13)  "the  uterus  is  represented  by  a  band  of 
muscular  fibre  and  connective  tissue  on  the  posterior  wall  of  the 
bladder. ' '  (Hart  and  Barbour. ) 

Describe  the  uterus  bipartitus. 

In  the  uterus  bipartitus  (see  Fig.  14)  the  rudimentary  horns  are 
present,  and  are  either  hollow  or  solid  and  cord-like  ;  they  are  con- 
nected to  each  other  and  to  the  vagina  by  the  cervix,  which  is  repre- 
sented by  a  fibrous  band.  The  ovaries,  breasts  and  external  genitals 
may  be  well  developed. 


MALFORMATIONS   OF  THE  UTERUS. 


107 


Describe  the  uterus  unicornis. 

The  body  of  the  uterus  in  this  variety  (see  Fig.  15)  is  long  and 
narrow,  and  is  directed  to  one  side ;  its  fundus  has  attached  to  it  one 
Fallopian  tube  and  ovary  ;  on  the  opposite  side  of  the  body  is  seen 
the  representative  of  the  other  horn,  which  is  either  solid  or  hollow ; 

Fig.  14. 


Uterus  Bipartitus  (Rokitansky).     V,  vagina ;  TJ,  uterus ;  h,  rudimentary  horn ;  Ot 
ovary;  T,  tube;  r,  round  ligament;  b,  broad  ligament. 


Fig.  15. 


Uterus  Unicornis  (Schroeder).  R,  right  side;  L,  left  side.  The  left  horn  (h)  is  well 
developed  and  communicates  with  the  uterine  cavity.  The  rigrht  horn  is  in  1he 
form  of  an  elongated  band;  its  point  of  connection  with  the  Fallopian  tube  is 
indicated  by  the  insertion  of  the  round  ligament,  which  is  hypertrophied.  Other 
letters  as  in  preceding  diagrams. 


connected  with  this,  and  separated  from  it  by  the  attachment  of  the 
round  ligament,  are  the  tube  and  ovary  of  that  side. 

Describe  the  uterus  bicornis. 

In  this  form  (see  Fig.  16)  the  division  into  two  horns  is  distinctly 
visible  externally  ;  the  division  is  usually  seen  also  in  the  interior  o£ 
the  uterus  on  section. 


108 


ESSENTIALS  OP  GYNECOLOGY. 


Fig.  16. 


Uterus  Bicornis  Unicollis  (Schroeder).    r,  round  ligament. 


Fig.  17. 


Uterus  Didelphys.  a,  right  cavity;  b,  left  cavity;  c,  right  ovary;  d,  right  round 
ligament;  e,  left  round  ligament;  /,  left  tulie;  g,  left  vaginal  portion  .  h,  right 
vaginal  portion;  i,  right  vagina;  }',  left  vagina;  k,  partition  between  the  two 
vaginse.    (From  De  Sinety,  after  Ollivier.) 


MALFORMATIONS   OF  THE  UTERUS. 


109 


What  is  the  uterus  didelphys  ? 

Here  the  two  halves  of  the  uterus  are  separated  throughout  (see 
Fig.  17).     This  condition  is  very  rare. 

Describe  the  uterus  septus. 

Here  the  division  is  entirely  internal  (see  Fig.  18) ;  beginning  at 
the  fundus,  it  extends  a  variable  distance  toward  the  os  externum, 
sometimes  reaching  it.  There  is  no  indication  of  the  division  from 
the  outside. 


Fig.  18. 


Fig.  19. 


Uterus  Septus  in  Vertical  Transverse  Section  (Kuss- 
maul).  Z7(uterus),  placed  on  septum  which  divides 
cavity  into  two  lateral  portions ;  T,  Fallopian  tubes ; 
V,  vagina  divided  into  lateral  cavities  by  prolonga- 
tion of  septum  downward. 


Infantile  Uterus 
(Schroeder). 


What  is  an  infantile  uterus  ? 

In  this  condition  (see  Fig.  1 9)  the  cervix  is  2-3  times  longer  than 
the  body,  the  relation  of  cervix  to  body  remaining  as  at  birth.  The 
uterus  as  a  whole  is  smaller  than  normal. 

What  is  meant  by  congenital  atrophy  of  the  uterus  ? 

The  relative  lengths  of  cervix  and  body  (see  Fig.  20)  conform  to 
those  of  a  virgin  uterus,  but  the  whole  uterus  is  atrophied. 


110 


ESSENTIALS   OF  GYNAECOLOGY. 


What  is  the  occurrence  of  complete  absence  of  the  uterus? 

It  is  very  rare  indeed,  and  can  only  be  ascertained  by  a  post- 
mortem examination.  Many  cases  of  supposed  absence  of  the  uterus 
are  proved,  on  autopsy,  to  be  cases  of  rudimentary  uterus. 


Fig.  20. 


Primary  Atrophy  of  the  Uterus  (Virchow). 


Displacements  of  the  Uterus. 

What  do  we  mean  by  a  displacement  of  the  uterus  in  a 
clinical  sense  ? 
"Changes  in  the  position  of  the  uterus  only  become  displacements, 
in  the  clinical  sense,  when  they  are  more  or  less  stable.  Limitation 
or  hindrance  of  the  normal  movements  of  the  uterus  is  a  main 
characteristic  of  its  displacements. ' '  (Schultzc. ) 

What  are  the  principal  displacements  of  the  uterus  1 

a.  Anteversion  ; 

b.  Anteflexion ; 

c.  Retroversion  ; 

d.  Retroflexion  ; 

e.  Prolapse. 


DISPLACEMENTS   OF  THE  UTERUS.  Ill 

What  is  the  difference  between  a  "version"  and  a  " flexion?" 

lb.  a  "version"  the  canals  of  the  cervix  and  body  are  in  the  same 
straight  line  ;  in  a  "  flexion ' '  they  make  an  angle  with  each  other. 

Ante  version. 

What  is  the  pathology  ? 

The  nterine  axis  is  straightened  (see  Fig.  21),  so  that  the  fundus 
lies  forward,  and  the  cervix  is  directed  backward  toward  the  hollow 

Fig.  21. 


Anteversion  of  the  Uterus  (Schroeder). 

of  the  sacrum ;  the  uterus  is  usually  enlarged  and  more  rigid, 
especially  about  the  internal  os.  The  anteverted  uterus  may  bt 
fixed  or  movable. 

What  is  the  etiology  ? 

The  chief  causes  are  those  of  a  metritis,  and  pelvic  peritonitis  or 
cellulitis,  thus  :  Subinvolution,  laceration  of  the  cervix,  with  sepsis, 
and  other  causes  of  pelvic  inflammation. 

What  are  the  symptoms  ? 

They  are  the  symptoms  of  the  accompanying  metritis,  peritonitis 
or  cellulitis.     One  of  the  most  marked  symptoms  is  frequent  mictu- 


112  ESSENTIALS   OF  GYNECOLOGY. 

rition,  due  to  the  pressure  of  the  uterus  ou  the  bladder,  the  uterus 
being  fixed  forward  and  not  allowing  the  bladder  to  expand  normally. 
Schroeder  describes  a  discomfort  arising  from  the  motion  of  the 
enlarged,  sensitive,  anteverted  uterus,  occurring  with  the  movements 
of  the  patient.     Menorrhagia  sometimes  occurs. 

What  are  the  physical  signs  ? 

The  cervix  is  far  back,  pointing  toward  the  hollow  of  the  sacruni  ; 
the  body  of  the  uterus  lies  just  above  the  anterior  vaginal  wall,  the 
fundus  just  behind  the  pubis.  The  normal  angle  between  cervix  and 
body  is  obliterated  ;  the  mobility  or  fixity  is  easily  detected. 

What  is  the  treatment  ? 

First  treat  the  accompanying  inflammation  by  hot-water  vaginal 
douches,  iodine  to  the  fornices,  and  boric  acid  and  glycerine  tampons 
behind  the  cervix,  or  both  in  front  and  behind.  Continue  this 
treatment  till  all  inflammatory  symptoms  have  subsided  and  the 
uterus  is  mobile.  Relief  is  then  often  given  by  such  a  pessary  as 
Emmet's,  the  posterior  bar  of  which,  when  placed  in  the  posterior 
fornix,  pushes  the  cervix  forward,  and  thus  raises  the  fundus  some- 
what from  the  bladder,  and  at  the  same  time  raises  the  uterus  a 
little  as  a  whole. 

Anteflexion. 

What  is  the  pathology  ? 

In  anteflexion  the  body  of  the  uterus  is  bent  forward  on  the 
cervix  (see  Fig.  22) ;  in  order  for  this  to  be  pathological,  there  must 
be  rigidity  at  the  point  of  flexion. 

What  is  the  etiology  ? 

It  may  be  congenital  (puerile,  Schultze)  or  acquired. 

The  most  common  causes  of  the  latter  are  a  metritis  occurring  in 
a  flexible  uterus,  or  an  inflammatory  process  occurring  in  the  utero- 
sacral  ligaments,  drawing  the  upper  portion  of  the  cervix  upward 
and  backward.  This  latter  is  the  most  usual  cause.  Bandl  thinks 
cervical  catarrh  the  first  cause,  extending  to  the  cervical  tissue,  and 
then  to  the  cellular  tissue  in  the  utero-sacral  ligament. 

It  is  sometimes  caused  by  the  adhesions  of  peritonitis  drawing  the 
uppei  portion  of  the  cervix  backward. 


DISPLACEMENTS   OF  THE  UTERUS. 


113 


What  are  the  symptoms  ? 

a.  Dysmenorrhea ; 

b.  Sterility ; 

c.  Disturbance  of  bladder  functions — frequent  micturition  ; 

d.  Leucorrboea ; 

e.  Other  symptoms  are  those  of  the  accompanying  inflammation. 

What  are  the  physical  signs  ? 

The  cervix  lies  rather  high ;   the  os  is  directed  downward  and 
forward ;  as  you  pass  the  finger  up  along  the  anterior  wall  of  the 

Fig.  22. 


Anteflexion  of  the  Uterus  (Schroeder). 


cervix,  it  runs  into  a  marked  angle  between  cervix  and  body.  The 
body  can  be  felt  lying  in  front  of  the  cervix,  just  above  the  anterior 
vaginal  wall.  The  cervix  is  often  long  and  the  os  small.  The  uterus 
is  sometimes  both  anteflexed  and  retroverted. 

From  what  must  you  differentiate  an  anteflexion  ? 

Prom — 1.  A  fibroid  tumor  in  the  anterior  wall  of  the  utsras  \ 
2.  An  inflammatory  deposit  in  front  of  the  cervix. 


114 


ESSENTIALS   OF   GYNAECOLOGY. 


Fig.  23. 


How  would  you  differentiate  an  anteflexed  uterus  from  a 
fibroid  tumor  in  the  anterior  wall  ? 
In  an  anteflexion  you  cannot  feel  the  fundus  elsewhere,  and  a 

sound  passes  when  sharply  curved 
into  the  body  felt  in  front  of  the 
cervix. 

In  a  fibroid  in  the  anterior  wall 
(see  Fig.  23)  the  sound  does  not 
pass  into  the  body  felt  in  front  of 
the  cervix,  but  behind  it,  and  the 
fundus  can  be  felt  above  and  behind 
the  fibroid. 


Sound  passed  to  show  that  a  Fibroid 
of  the  Anterior  Wall  is  not  an 
Anteflexion  (Leblond). 


How  would  you  differentiate 
an  inflammatory  deposit 
from  an  anteflexion  ? 

The  former  is  comparatively  rare, 
but  when  present  is  usually  more 
sensitive  than  an  anteflexion ;  in 
the  case  of  an  inflammatory  deposit 
in  front  of  the  cervix,  a  careful 
bimanual  examination  will  usually 
show  the  fundus  elsewhere. 
During  the  acute,  inflammatory  period  the  sound  is  contra- 
indicated. 

What  is  the  treatment  of  anteflexion  ? 

First  treat  all  existing  pelvic  inflammation. by  means  of  hot-water 
douches,  counter-irritation  and  glycerine  tampons.  When  all  inflam- 
matory symptoms  have  subsided,  dilate  the  cervix,  under  antiseptic 
precautions,  with  one  of  the  glove-stretcher  dilators,  and  apply 
caroolic  acid  or  iodized  phenol  to  the  region  of  the  internal 
os.  Maintain  the  dilatation  by  the  introduction  of  the  graduated 
ham  dilators,  or  sounds,  once  or  twice  a  month  for  two  to  three 
months. 

Some  employ  the  intra -uterine  stem  for  maintenance  of  the  dila- 
tation, but  this  is  accompanied  by  danger. 

Quterbridge's  wire  tubes  are  also  <inployed  for  this  purpose. 


DISPLACEMENTS    OF  THE  UTERUS. 


115 


Retroversion  and  Retroflexion. 
Define. 

"Retroversion  may  be  defined  as  the  permanent  dislocation  back- 
ward of  the  fundus  uteri,  when  the  form  of  the  uterus  is  such  that 
axis  of  body  and  axis  of  cervix  are  identical.  Retroflexion  denotes 
the  permanent  backward  dislocation  of  the  fundus  uteri,  with  simul- 
taneous flexion  of  the  uterus  over  the  posterior  surface. ' '  (Harrison. ) 

What  is  the  etiology  and  pathology  ? 

Retroversion  (see  Fig.  24)  may  exist  by  itself,  but  with  retroflexion 
•here  is  always  more  or  less  retroversion.     Usually  the  uterus  is  first 

Fig.  24. 


Retroversion  of  the  Uterus  (Schroeder.) 


retroverted,  and  then  intra-abdominal  pressure  continuing,  if  the 
uterus  is  flexible,  the  fundus  is  pushed  backward  and  downward. 
The  combination  of  the  two  is  thus  most  common,  and  is  described 
as  retroversio-flexio  (see  Fig.  25).  Retroversio-flexio  is  most  fre- 
quent in  multiparas  following  parturition,  where  the  ligaments  are 
lax  and  patient  lies  on  the  back,  and  especially  if  the  patient  rises 
before  involution  has  occurred.    It  may  occur,  however,  in  nulliparae 


116 


ESSENTIALS   OF   GYNECOLOGY. 


or  virgins,  from  severe  blows,  falls,  lifting,  straining,  etc. ;  also  from 
inflammatory  adhesions,  drawing  the  uterus  backward. 

The  most  common  agent  in  pushing  a  movable  uterus  behind  the 
perpendicular  is  distention  of  the  bladder ;  intra-abdominal  pressure 
may  then  act  on  the  anterior  surface  of  the  uterus.  Relaxation  of 
the  utero-sacral  ligaments,  and  thickening  and  shortening  of  the 
utero-vesical,  favor  retroversio-flexio. 

Pathologically,  we  usually  find  the  body  of  the  uterus  congested 
and  enlarged,  and  more  or  less  rigidity  at  the  junction  of  cervix  And 
body,  from  development  of  fibrous  tissue. 

Fig.  C5. 


Retroversiu-flexio. 


What  are  the  symptoms  ? 

1 .  More  or  less  constant  pain  in  the  back  °. 

2.  Symptoms  of  pelvic  inflammation ; 

3.  Constipation  ; 

4.  Irritability  of  the  bladder  ; 

5.  Leucorrhoea  ; 
0.   Menorrhagia; 

7.  Dysmenorrheea,  especially  when  flexion  is  marked; 


DISPLACEMENTS   OF  THE  UTERUS.  117 

8.  Abortion ; 

9.  Sterility; 

10.  Reflex  neuroses. 

What  are  the  physical  signs  ? 

On  making  the  bimanual  examination,  you  find  the  cervix  nearer 
the  vulva  than  normal,  the  fundus  absent  in  front,  and  the  os  pointing 
more  or  less  forward  ;  on  running  the  vaginal  fingers  along  the  pos- 
terior wall  of  the  cervix,  you  find  a  body  which,  in  a  retroversion, 
continues  the  line  of  this  wall,  in  a  retroflexion  makes  an  angle  with 
it.  This  body  moves  as  a  part  of  the  uterus ;  the  sound  passes 
into  it. 

From  what  must  you  differentiate  retroversio-flexio  ? 

1 .  Fibroid  tumor  on  posterior  wall  of  the  uterus  ; 

2.  Faeces  in  the  rectum  ; 

3.  Inflammatory  deposits ; 

4.  Prolapsed  ovaiy  or  small  ovarian  tumor. 

How  would  you  differentiate  retroversio-flexio  from  a  fibroid 
on  the  posterior  wall  ? 

Make  a  careful  bimanual  examination.  In  case  of  a  backward 
displacement  of  the  uterus,  we  find  an  absence  of  the  fundus  in  front, 
the  cervix  points  more  or  less  forward,  and  the  sound,  when  intro- 
duced, goes  backward. 

In  case  of  a  fibroid  on  the  posterior  wall,  the  fundus  may  be  felt 
in  front  of  it,  and  the  sound  passes  forward.  The  tumor  may  feel 
more  irregular  and  harder  than  the  uterus. 

How  would  you  differentiate  the  fundus  uteri  from  faeces  in 
the  rectum  ? 

On  bimanual  examination,  the  fundus  can  often  be  felt  forward, 
and  the  sound  passes  forward  ;  the  fseces  have  a  more  doughy  feel 
than  the  uterus ;  if  doubt  exists,  always  empty  the  rectum  before 
making  a  diagnosis. 

How  would  you  differentiate  the  fundus  uteri  from  inflam- 
matory deposits  in  the  pouch  of  Douglas  ? 

During  the  stage  of  acute  inflammation  this  may  be  veiy  difficult, 
as  the  sound  is  then  contraindicated.  Finding  the  fandus  in  front 
is  the  chief  element  in  the  diagnosis. 


118  ESSENTIALS  OF  GYNECOLOGY. 

When  acute  inflammation  has  subsided,  introduction  of  the  sound 
will  give  great  assistance. 

How  would  you  differentiate  the  fundus  uteri  from  a  pro- 
lapsed ovary  or  small  ovarian  tumor  ? 
By  making  a  careful  bimanual  examination,  the  uterus  is  found 
lying  in  front  of  the  prolapsed  ovary  or  tumor.  Assistance  may  be 
given  by  the  use  of  the  sound,  or  drawing  down  the  cervix  with  a 
volsella. 

What  are  the  indications  in  the  treatment  of  retroversio- 
flexio? 

1.  To  treat  the  pelvic  peritonitis  or  cellulitis,  if  present,  according 

to  the  regular  methods ; 

2.  To  replace  the  uterus  ; 

3.  To  retain  it  in  place. 

What  are  the  methods  of  replacing  a  retroverted  or  retro- 
flexed  uterus  when  movable  ? 

1 .  Place  the  patient  in  Sims'  position ;  introduce  index  and  middle 
fingers  of  the  right  hand  into  the  posterior  fornix  vaginae ;  have 
patient  breathe  deeply  and  slowly ;  during  an  expiration,  raise  the 
body  of  the  uterus  with  the  backs  of  the  vaginal  fingers  till  it  passes 
the  promontory  of  the  sacrum,  then  transfer  one  or  both  fingers  to 
the  front  of  the  cervix,  and  push  that  backward ;  this  throws  the 
fundus  forward. 

2.  Another  method  is  to  replace  the  uterus  while  patient  is  in  the 
dorsal  position,  by  means  of  the  bimanual,  either  vagino-abdominal 
or  recto-abdominal.  In  this  method  the  body  of  the  uterus  is  raised 
by  the  fingers  in  the  vagina  or  rectum  until  it  can  be  grasped  by  the 
external  hand,  when  it  is  then  brought  forward. 

3.  When  the  body  of  the  uterus  is  very  sensitive,  so  that  pressure 
by  the  fingers  is  very  painful,  the  uterus  may  be  replaced  by  means 
of  the  sound,  as  follows:  Introduce  the  sound  with  the  concavity 
backward;  then  make  the  handle  describe  an  arc  of  a  circle  from 
behind  forward ;  then  slowly  depress  the  handle  toward  the  perineum ; 
this  throws  the  uterus  forward. 

4.  To  replace  the  gravid  uterus,  the  following  method  is  sometimes 
employed:  Place  patient  in  the  genu-pectoral  position;  drawdown 


PESSARIES.  119 

cervix  with  the  vulsella,  and  press  fundus  uteri  toward  the  bladder, 
with  the  finger  in  the  rectum. 

When  the  uterus  in  a  retroversio-flexio  is  rigid  at  the  angle  of 
flexion,  we  do  not  expect  to  remove  the  flexion,  but  only  to  correct 
the  version. 

What  are  the  methods  of  replacing  a  retroverted  or  retro- 
flexed  uterus  when  fixed  by  adhesions  ? 

If  signs  of  pelvic  inflammation  are  present,  treat  the  inflammation 
by  hot  douches,  sitz-baths,  wet  pelvic  packs,  attention  to  the  bowels, 
etc.  When  the  inflammation  has  subsided,  the  uterus  may  gradu- 
ally be  replaced  by  cautious  manipulation  and  stretching  of  the 
adhesions,  and  gentle  attempts  at  raising  the  uterus,  a  few  moments 
at  a  sitting,  with  the  fingers  in  the  posterior  fornix  vaginae ;  after 
the  manipulation  insert  a  tampon,  to  be  worn  for  twenty-four  hours. 
The  manipulations  may  be  assisted  by  hot-water  vaginal  douches 
between  the  sittings. 

Schultze's  method  of  forcible  reposition  consists  in  placing  the 
patient  under  anaesthesia,  in  the  lithotomy  position,  inserting  index 
and  middle  fingers  of  left  hand  high  up  into  the  rectum,  and  with 
these  fingers  forcibly,  but  gradually,  elevating  the  fundus  uteri  and 
breaking  up  the  adhesions ;  the  right  hand  is  placed  on  the  abdo- 
men, and  as  the  uterus  is  elevated,  it  is  grasped  by  this  external 
hand  and  brought  forward. 

This  method  is  rarely  advisable. 

What  are  the  means  for  retaining  the  uterus  in  place  after 
reposition? 

1.  Pessaries ; 

2.  Operative  procedures. 


Pessaries. 

What  are  the  varieties  in  most  common  use  ? 

1.  The  Albert  Smith  ; 

2.  The  Emmet; 

3.  The  Thomas. 
Describe  them. 

They  are  all  usually  made  of  hard  rubber. 


120 


ESSENTIALS  OF  GYNAECOLOGY. 


The  Albert  Smith  (see  Fig.  26)  is  a  modification  of  the  Hodge 
pessary ;  its  anterior  extremity  is  narrow,  the  posterior  broad ;  the 
posterior  extremity  curves  upward  behind  the  cervix,  the  anterior 
downward  away  from  the  urethra. 

The  Emmet  pessary  is  usually  made  of  a  larger  bar  than  the  Albert 
Smith,  and  the  curve  is  much  flattened. 

The  Thomas  (see  Fig.  27)  is  long,  narrow,  and  has  its  posterior 
bar  much  enlarged. 


Fig.  26. 


Fig.  27. 


Albert  Smith  Pessary. 


Thomas  Pessary. 


How  does  a  retroversion  pessary  act  ? 

Not  by  pushing  up  the  body  or  fundus,  but  by  making  the  poste 
rior  vaginal  wall  tense,  thus  drawing  the  cervix  backward,  and  in 
this  way  throwing  the  fundus  forward. 

What  are  the  contraindications  to  the  use  of  a  pessary  ? 

A  pessary  should  not  be  introduced  till  all  pelvic  inflammation  has 
subsided,  and,  as  a  rule,  not  until  the  uterus  can  be  well  brought 
forward ;  ' '  but  occasionally,  when  the  uterus  is  elevated  to  about 
the  promontory^  the  pessary  may  be  applied." 

What  is  the  proper  position  of  a  retroversion  pessary  after 
introduction  ? 

The  broader  extremity  should  lie  behind  the  cervix  and  curve 
upward  ;  the  narrow  in  front  and  curve  downward. 


PESSARIES. 


121 


How  would  you  introduce  one  of  these  retroversion  pessaries? 

They  may  be  introduced  with  patient  either  in  the  dorsal  or  in 
Sims'  position,  preferably  in  the  latter,  and  in  the  following  manner : 
Standing  at  the  side  of  the  table,  near  the  buttocks  of  the  patient, 
separate  the  labia  a  little  with  the  fingers  of  the  left  hand  ;  taking 


Fig.  28. 


Introduction  of  Pessary,  First  Stage  (Hart  and  Barbour). 

the  pessary  by  the  smaller  end  with  the  thumb  and  index  and  middle 
fingers  of  the  right  hand,  introduce  it  between  the  labia,  with  the 
breadth  of  the  pessary  in  the  line  of  the  labia  (see  Fig.  28)  ;  depress 
the  perineum  with  the  pessaiy  as  you  introduce  it  about  half  way, 


122 


ESSENTIALS  OF  GYNECOLOGY. 


then  rotate,  so  that  the  breadth  of  the  pessary  lies  at  right  angles  to 
the  labia ;  now  grasp  the  external  portion  of  the  pessary  with  the 
left  hand  ;  pass  the  index  finger  or  index  and  middle  fingers  of  the 
right  hand  in  front  of  the  posterior  bar  (see  Fig.  29)  and  cany  the 
pessary  along  the  posterior  vaginal  wall,  being  careful  that  it  does 
not  slip  up  in  front  of  the  cervix. 

Fig.  29. 


Second  Stage :  Pessary  carried  on  by  Finger  (Hart  and  Barbour). 

What  are  the  precautions  to  be  observed  in  the  employment 
of  a  pessary  ? 
A  patient  after  the  introduction  of  a  pessary  should  be  made  to 
walk  a  little  about  the  room,  then  to  sit  on  a  chair  and  cross  one 
knee  over  the  other,  to  ascertain  if  the  pessary  causes  pain;  if  it 
does,  it  should  not  be  kept  iii.  A  patient  should  always  be  told,  on 
leaving,  that  if  the  pessary  causes  her  pain,  she  must  introduce  her 
finger  and  remove  it.      She  should  be  seen  in  a  few  days  after  its 


PESSARIES.  1^3 

introduction,  to  ascertain  if  the  pessary  is  in  position  and  is  holding 
the  uterus  in  place.  The  pessary  should  be  removed  and  cleaned 
as  often  as  once  a  month ;  in  the  meantime  the  patient  should  be 
instructed  to  use  a  vaginal  douche  for  cleanliness,  two  to  three  times 
a  week. 

What  are  the  operative  procedures  for  holding  a  retroverted 
uterus  in  place  after  reposition  ? 

a.  Alexander's  operation ; 

b.  Hysterorrhaphy. 

Describe  briefly  Alexander's  operation. 

Alexander's  operation  for  shortening  the  round  ligaments  is  per- 
formed as  follows :  The  skin  about  the  pubes  is  shaved  and  prepared 
antiseptically ;  the  pubic  spine  is  taken  as  the  first  landmark ;  an 
incision  is  then  made,  1J-3  inches  long,  from  that  point  upward  and 
outward,  in  the  direction  of  the  inguinal  canal ;  the  incision  is  deep- 
ened until  the  tendon  of  the  external  oblique  is  seen  ;  the  external 
abdominal  ring  is  now  visible ;  the  intercolumnar  fascia  is  cut  through 
in  the  long  diameter  of  the  ring ;  the  round  ligament  can  usually 
now  be  seen,  with  the  genital  branch  of  the  genito-craral  nerve  along 
its  anterior  surface.  The  ligament  is  then  separated  from  neighboring 
structures  and  gently  drawn  out  a  little  to  show  it  is  free.  Alexander 
then  leaves  this  side  covered  with  a  clean  sponge  and  operates  on 
the  other  side  in  the  same  way.  The  uterus  is  then  thrown  for- 
ward by  the  sound  in  the  hands  of  an  assistant  and  the  ligaments 
drawn  out  till  they  are  felt  to  control  the  uterus;  the  ligaments 
are  then  given  to  an  assistant  to  hold,  and  they  are  each  sutured 
with  catgut  to  the  pillars  of  the  ring ;  the  bruised  ends  are  cut 
off  and  the  remainder  stitched  in  the  external  wound  ;  a  fine  drain  - 
age  tube  is  inserted  and  an  antiseptic  dressing  applied.  The  patient 
is  kept  in  bed  two  to  three  weeks,  and  wears  a  pessary  for  several 
months. 

What  are  the  objections  raised  to  Alexander's  operation? 

It  is  not  applicable  unless  the  uterus  is  freely  movable. 
The  ligaments  are  sometimes  difficult  to  find. 
Unless  a  firm  perineal  support  is  built  up,  the  uterus  is  very  apt 
to  resume  its  former  malposition. 


124  ESSENTIALS   OF  GYNECOLOGY. 

Describe  briefly  the  operation  of  hysterorrhaphy  for  retro- 
versio  flexio. 

The  abdomen  is  opened  in  the  median  line  as  for  an  ovariotomy  ; 
the  adhesions  binding  the  uterus  backward  are  broken  up,  the  fundus 
brought  forward  and  the  uterus  stitched  with  hardened  catgut  to  the 
anterior  abdominal  wall,  the  sutures  being  passed  into  the  uterus  at 
the  insertion  of  the  round  ligaments.  The  abdominal  wound  is  closed 
in  the  usual  manner  and  an  antiseptic  dressing  applied.  A  vaginal 
pessary  is  usually  inserted  for  a  time. 

Prolapsus  Uteri. 

What  is  meant  by  the  expression  ? 

Hart  and  Barbour  define  prolapsus  uteri  as  a  downward  displace- 
ment of  entire  displaceable  portion  of  pelvic  floor,  uterus  and  ap- 
pendages past  entire  fixed  portion,  with  coincident  descent  of  small 
intestine. 

What  is  meant  by  the  "entire  displaceable  portion  of  pelvic 
floor"? 

' '  The  entire  displaceable  portion  comprises  bladder,  urethra  and 
vaginal  walls.  It  has  resting  upon  it  the  uterus,  broad  ligament, 
Fallopian  tubes  and  ovaries. ' ' 

What  is  the  "  entire  fixed  portion  of  pelvic  floor  "  ? 

That  outside  of  the  entire  displaceable  portion,  i.  e.,  tissue  attached 
to  the  posterior  surface  of  the  symphysis ;  all  outside  the  inner 
aspect  of  the  levatores  ani ;  the  rectum  and  tissue  attached  to  the 
sacrum. 

What  are  the  degrees  of  prolapsus  uteri  ? 

According  to  Thomas  there  are  three  : — 

1 .  When  the  organ  has  sunk  in  the  pelvis. 

2.  When  the  cervix  is  at  the  ostium  vaginae. 

3.  When  a  part  or  the  whole  of  the  uterus  lies  between  the  thighs. 

What  is  the  etiology  ? 

The  three  elements  in  the  etiology  of  prolapse  are — 
1.  Relaxation  of  the  ligaments  of  the  uterus,  combined  with  lack 
of  tone  in  the  entire  displaceable  portion  of  the  pelvic  floor  and 
slackening  of  loose  tissue  around  it. ' ' 


PROLAPSUS  UTERI.  125 

2.  Lack  of  support  in  the  entire  fixed  portion  of  the  pelvic  floor, 
especially  laceration  of  the  perineum. 

3.  Intra-abdominal  pressure. 

The  chief  predisposing  causes  are  parturition,  laborious  occupa- 
tions, anything  increasing  weight  of  the  uterus,  advanced  age.  Pro- 
lapse is  sometimes  produced  acutely  by  blows,  falls,  heavy  lifting, 
etc. ,  but  is  usually  the  gradual  result  of  the  three  elements  mentioned 
above. 

What  are  the  symptoms  ? 

Those  of  the  acute  prolapse  are  sudden,  severe  pain,  vomiting, 
retention  of  urine  and  signs  of  peritonitis.  The  symptoms  of  the 
gradual  prolapse  are  a  dragging  sensation  in  lower  abdomen  and 
back,  and  the  discomfort  from  the  protrusion  and  excoriation  of  the 
parts  ;  difficulty  in  urination  is  sometimes  present. 

What  are  the  physical  signs  ? 

These  depend  on  the  degree  of  the  prolapse.  If  the  prolapse  is 
partial,  the  anterior  vaginal  wall  bulges  at  the  ostium  vaginae,  the 
cervix  is  lower  than  normal,  and  if  there  is  marked  laceration  of  the 
perineum  the  posterior  vaginal  wall  also  bulges.  The  uterus  becomes 
more  and  more  retroverted  as  it  sinks  in  the  pelvis.  When  the  pro- 
lapse is  complete,  the  cervix  and  more  or  less  of  the  body  of  the 
uterus  lies  outside  of  the  vulva;  the  anterior  vaginal  wall  and  part  of 
the  lower  bladder  wall  have  prolapsed  with  the  cervix;  the  posterior 
vaginal  wall  with  or  without  part  of  the  anterior  rectal  wall  is  also 
everted.    The  uterus  is  usually  enlarged  and  the  cervix  elongated. 

From  what  must  you  differentiate  prolapsus  uteri  ? 

1.  Hypertrophy  of  the  cervix  : — 

(a)  Vaginal  portion. 

(b)  Supra-vaginal  portion. 

(c)  Intermediate  portion. 

2.  Cystocele. 

3.  Rectocele. 

4.  Inversion  and  polypi. 

How  would  you  differentiate  prolapsus  uteri  from  a  cysto- 
cele? 
In  prolapse  the  uterus  is  suuken  in  the  pelvis  ;  in  cystocele  the 


126  ESSENTIALS   OF  GYNAECOLOGY. 

uterus  lies  in  its  normal  position,  and  the  protruding  mass  is  found, 
by  the  introduction  of  the  sound  into  the  bladder,  to  consist  of  the 
anterior  vaginal  and  posterior  vesical  wall. 

How  would  you  differentiate  prolapsus  uteri  from  a  recto 
cele? 

In  prolapse  the  uterus  is  sunken  in  the  pelvis  ;  in  rectocele,  pure 
and  simple,  the  uterus  lies  in  its  normal  position,  and  the  protruding 
mass  is  found,  by  the  introduction  of  the  finger  into  the  rectum,  to 
consist  of  the  posterior  vaginal  and  anterior  rectal  wall. 

Both  cystocele  and  rectocele  are  common  complications  of  prolap- 
sus uteri. 

What  is  the  treatment  of  prolapsus  uteri  ? 

1.  By  pessaries. 

2.  By  operation. 

If  the  prolapse  is  slight  in  amount,  the  perineum  preserved,  and 
the  anterior  vaginal  wall  protrudes  but  a  little,  a  pessary,  like  that 
of  Albert  Smith,  may  suffice  to  hold  up  the  uterus.  If  this  fails,  a 
cradle  pessary  will  sometimes  answer, 

If  the  perineum  is  badly  lacerated,  or  there  is  much  cystocele,  an 
operation  is  imperative. 

The  operative  procedures  are  : — 

1.  That  which  restores  the  perineal  support  and  unites  the  lower 
portion  of  the  labia  majora — episioperineorrhaphy. 

2.  That  which  combines  with  the  latter  a  "  reefing  "  of  the  ante- 
rior vaginal  wall — anterior  colporrhaphy,  with  or  without  amputa- 
tion of  the  cervix. 

3.  That  which  combines  episioperineorrhaphy  with  Alexander's 
operation,  or  hysterorrhaphy. 

4.  Vaginal  hysterectomy. 

What  are  the  indications  for  these  different  operations  ? 

Where  the  prolapse  is  slight,  of  the  first  or  second  degree 
(Thomas),  with  little  or  no  cystocele,  episioperineorrhaphy  will  usu- 
ally suffice;  it  may  be  supplemented  by  the  use  of  a  pessary.  When 
the  prolapse  is  more  marked  and  associated  with  cystocele,  the  sec- 
ond procedure  is  indicated,  with  amputation  of  the  cervix,  if  this  is 
greatly  hypertrophied.  Some  operators,  in  cases  of  marked  prolapse, 
prefer  the  combination  of  episioperineorrhaphy  with  hysterorrhaphy 


LACERATION  OP  PERINEUM.  127 

or  Alexander's  operation,  to  the  method  just  described.  Vaginal 
hysterectomy  for  prolapse  is  only  indicated  where  the  prolapse  is 
complete,  and  other  methods  seem  impracticable. 


Laceration  of  Perineum  and  Relaxation  of  Vagi- 
nal Outlet. 

What  is  the  etiology  ? 

The  most  common  cause  of  laceration  of  the  perineum  is  child- 
birth, either  natural  or  instrumental ;  rarely,  however,  it  may  arise 
from  external  violence,  as  falling  astride  of  some  sharp  object.  Re- 
laxation of  the  vaginal  outlet,  aside  from  being  produced  by  these 
visible  lacerations,  is  also  caused  by  submucous  and  subcutaneous 
rupture  or  overstretching  of  the  fibres  of  the  levator  ani  muscle,  or 
perineal  fascia  ;  this,  too,  occurs  most  often  during  parturition. 

What  are  the  varieties  of  perineal  laceration  ? 

The  laceration  may  be  slight,  involving  the  fourchette,  and  extend- 
ing a  short  distance  on  the  skin  surface  of  the  perineum. 

It  may  be  extensive,  beginning  with  the  fourchette  and  extending 
through  the  sphincter  ani  and  some  distance  up  the  rectum. 

It  may  be  chiefly  internal,  the  skin  perineum  being  preserved ; 
these  internal  lacerations  are  usually  lateral,  extending  into  the  vagi- 
nal sulci  on  either  side  of  the  columna,  and  either  side  of  the  rec- 
tum ;  they  are  often  bilateral. 

What  is  the  importance  of  laceration  of  the  perineum  ? 

It  consists  in  the  fact  that  in  cases  of  marked  laceration,  the  fibres 
of  the  levatores  ani,  the  chief  support  of  the  vaginal  outlet,  are  torn; 
especially  those  fibres  which  are  attached  to  the  rectum  ;  at  the  same 
time  there  is  laceration  of  the  fibres  of  the  perineal  fascia.  These 
conditions  cause  relaxation  of  the  vaginal  outlet,  with  a  tendency  to 
rectocele,  cystocele  and  prolapsus  uteri. 

If  the  laceration  is  through  the  sphincter  ani,  incontinence  of 
faeces  usually  results. 

What  are  the  subjective  symptoms  of  laceration  of  the  peri- 
neum with  relaxation  of  the  vaginal  outlet  ? 

The  patient  usually  feels  incapacitated  for  any  great  exertion, 


128  ESSENTIALS   OF  GYNECOLOGY. 

complains  of  a  dragging  pain  in  the  back  and  the  feeling  of  weight 
in  the  pelvis. 

How  would  you  determine  relaxation  of  the  vaginal  outlet  ? 

Insert  the  thumbs  or  index  fingers  into  the  vaginal  orifice  ;  sepa- 
rate the  labia  by  carrying  the  thumbs  or  fingers  backward  and  out- 
ward, at  the  same  time  telling  the  patient  to  strain  ;  the  lax  condi- 
tion of  the  outlet  will  then  be  readily  felt,  and  anterior  and  posterior 
vaginal  walls  will  be  seen  to  protrude. 

What  are  the  principal  operative  procedures  for  repair  of 
lacerated  perineum  or  relaxation  of  the  vaginal  outlet  ? 

The  two  chief  operations  are — 

1 .  Saenger's  modification  of  Tait's  operation. 

2.  Emmet's  operation. 

Describe  the  Saenger-Tait  operation. 

The  patient  is  prepared  for  operation  by  having  the  bowels  freely 
moved,  the  vulva  shaved,  and  an  antiseptic  vaginal  douche  given. 
She  is  then  anaesthetized  and  placed  in  the  lithotomy  position,  with 
knees  supported  by  Kelly's  "leg  holder"  and  hips  resting  on  Kelly's 
perineal  pad.  The  vagina  and  vulva  are  now  irrigated  with  an 
antiseptic  solution,  and  an  assistant  so  stationed  that  he  can  allow  a 
mild  antiseptic  solution  or  boiled  water  to  trickle  on  the  wound 
during  the  operation.  A  tampon  is  inserted  into  the  rectum,  the 
string  left  projecting.  The  index  and  middle  fingers  of  the  left 
hand  are  now  inserted  into  the  rectum,  as  seen  in  Fig.  30;  the 
labia  are  separated  by  an  assistant,  the  blades  of  the  scissors  (Tait 
uses  angular  scissors  and  inserts  only  one  blade;  scissors  curved 
slightly  on  the  flat,  with  points  rather  sharp,  and  both  blades  in- 
serted,  may  be  used  with  advantage)  inserted  into  the  recto-vaginal 
septum  just  in  front  of  the  anus,  and  the  vaginal  and  rectal  mucous 
membranes  separated  for  some  distance  around  the  point  of  inser- 
tion. A  horizontal  incision  is  now  made  through  the  point  of  inser- 
tion, extending  on  either  side  to  a  perpendicular  through  the  lower 
extremity  of  the  nymphae  ;  an  incision  is  made  with  the  scissors  up 
along  this  perpendicular  to  the  lower  extremity  of  the  nymphae. 
Tlic  flap  so  marked  out  is  then  dissected  up  to  the  crest  of  the 
bulging  posterior  vaginal  wall.     See  Fig.  31. 


LACERATION  OF  PERINEUM. 


129 


The  parts  are  now  freshly  irrigated,  and  trie  sutures  of  silver  wire 
introduced  as  follows  :  Either  a  Peaslee's  needle  or  a  long,  straight 
needle  with  a  thread  loop  may  be  used  ;  the  sutures,  3-4  in  number, 


Fig.  30. 


are  inserted  just  within  the  denuded  area  on  one  side,  and  brought 
out  just  within  the  denuded  area  on  the  other.  See  Fig.  32.  The 
tampon  is  removed  from  the  rectum,  the  sutures  twisted  up  and 
either  left  long  or  shotted  and  cut  short.  The  skin  is  now  brought 
9 


130 


ESSENTIALS   OF   GYNAECOLOGY. 


Fig.  31. 


Fig.  32. 


LACERATION   OF  PERINEUM. 


131 


iDto  apposition  by  superficial  silkworm-gut  sutures  introduced  be- 
tween the  wires,  giving  the  result  seen  in  Fig.  33.  An  antiseptic 
dressing  and  a  T-bandage  are  applied,  and  the  patient  is  put  to  bed. 
The  bowels  are  moved  about  the  third  day,  and  the  sutures  re- 
moved on  the  eighth. 


Fig.  33. 


Fig.  34. 


'What  modification  of  this  operation  can  be  made  when  the 
laceration  extends  through  the  sphincter  ani  ? 

Begin  the  vaginal  flap  as  before  (see  Fig.  30)  ;  as  soon  as  the  lower 
portion  has  been  separated,  denude  a  narrow  Y-shaped  area,  with 
apex  up  the  rectum,  representing  the  torn  wall  of  the  latter,  and 
with  the  arms  of  the  V  resting  on  the  ends  of  the  divided  sphincter 
muscle ;  the  denuded  surface  may  be  a  little  larger  at  these  latter 
points.  Sutures  of  chromicized  catgut  or  silkworm  gut  are  now 
introduced,  as  seen  in  Fig.  34,  with  ends  in  the  rectum.  A  wire 
tension  suture  is  inserted  around  this  V,  entering  the  skin  at  3, 
passing  through  the  end  of  the  sphincter  muscle,  then  up  around 


132  ESSENTIALS   OF   GYNAECOLOGY. 

the  apex  2,  and  down  through  sphincter  muscle  and  skin  at  1 .  The 
gut  sutures  are  now  tied  in  the  rectum,  beginning  above  ;  the  wire 
is  not  twisted  until  later.  The  vaginal  flap  is  now  dissected  up  and 
wire  sutures  introduced  as  before.  (See  Fig.  32.)  The  wires  are 
now  all  twisted  up,  the  skin  brought  into  apposition  with  silkworm 
gut,  and  an  antiseptic  dressing  applied. 

Describe  Emmet's  operation  for  restoration  of  the  perineum. 

The  patient  is  prepared  for  operation  as  usual,  with  antiseptic 
douches,  etc.  She  is  anaesthetized  and  placed  in  the  lithotomy 
position  ;  a  point  is  selected  in  the  centre  of  the  crest  of  the  bulging 
posterior  vaginal  wall,  and  a  point  on  each  labium  niajus  correspond- 
ing to  the  lowest  vestige  of  the  hymen.  These  three  points  are  to 
be  brought  together  by  the  completed  operation. 

Between  the  central  point  chosen  and  the  two  lateral  are  two  triangu- 
lar areas,  with  apices  running  into  the  vaginal  sulci  on  each  side  of  the 
columna.  These  triangular  areas  are  first  denuded  as  follows  :  One 
tenaculum  is  inserted  into  the  central  point  chosen,  and  another  into 
one  of  the  lateral  points  ;  these  are  given  to  an  assistant,  who  draws 
the  central  point  forward  and  to  the  side  opposite  the  other  tenacu- 
lum. This  draws  the  apex  of  the  triangle  nearly  in  line  with  the  two 
tenacula  ;  a  narrow  strip  is  then  denuded  with  the  scissors  along  this 
line.  When  the  tension  is  relieved,  the  area  marked  off  is  seen  to 
be  triangular,  as  before.  The  denudation  of  this  triangle  is  then 
completed  by  long  snips  of  the  scissors.  The  lateral  point  on  the 
other  side  is  now  seized  with  the  tenaculum,  and  the  central  point 
drawn  toward  the  denuded  side  ;  this  triangle  is  denuded  as  before, 
also,  as  much  of  the  skin  surface  of  the  perineum  as  is  necessary. 
The  parts  are  now  thoroughly  irrigated  and  the  sutures  introduced  as 
follows :  The  two  triangular  areas  are  to  be  in  the  vagina,  and  are 
sutured  with  either  silkworm  gut,  chromicized  catgut  or  silk.  The 
apex  of  one  triangle  is  first  closed,  the  suture  entering  and  emerging 
from  the  vaginal  mucous  membrane  near  the  denuded  surface  ;  the 
succeeding  sutures  of  this  triangle  are  made  to  enter  the  vaginal 
mucous  membrane  on  one  side,  slant  toward  the  operator,  emerge  at 
the  centre  of  the  denuded  surface,  reenter,  slant  away  from  the 
operator  and  emerge  from  the  mucous  membrane  of  the  other  side 
9  \HV.  in  front  of  the  preceding  suture.     This  method  is  repeated  in 


LACERATION   OF  PERINEUM. 


133 


the  other  triangle.  There  then  remains  but  a  small  external  denuded 
area  to  be  closed  ;  this  is  best  done  with  silver  wire.  The  upper  or 
crown  suture,  entering  the  skin  on  one  side,  passes  through  the  anterior 
extremity  of  the  columna  of  the  posterior  vaginal  wall,  and  emerges 
from  the  skin  on  the  other  side.  The  bowels  are  moved  about  the 
third  day  and  the  sutures  removed  on  the  eighth. 

What  modification  does  episioperineorrhaphy  make  in  these 
operations  ? 

The  denudation  is  carried  higher  on  the  labia  majora  (see  Fig.  35), 
and  the  lower  portions  of  the  latter  are  united  as  seen  in  Fig.  36. 


Fig.  35. 


Fig.  36. 


Describe  the  operation  anterior  colporrhaphy. 

This  consists  in  the  excision  of  an  elliptical  piece  of  mucous  mem- 
brane from  the  anterior  wall  of  the  vagina,  and  suturing  together 
the  edges  of  the  mucous  membrane.  The  ellipse  should  extend 
from  the  urethral  prominence  to  a  point  a  little  in  front  of  the  cer- 
vix. The  incision  which  defines  the  ellipse  should  penetrate  the 
entire  thickness  of  the  mucous  membrane  ;  the  flap  is  then  dissected 
off.'  The  suturing  is  best  done,  according  to  Martin's  method,  by  a 
continuous  suture  of  chromicized  catgut,  as  follows  :  A  line  of  suture 


134  ESSENTIALS   OF  GYNJSCOLOGY. 

is  first  made  longitudinally  along  the  centre  of  the  denuded  ellipse  ; 
this  reduces  its  size  slightly  ;  another  tier  of  sutures  is  then  inserted 
back  over  the  first,  uniting  tissue  more  superficial  ;  thus  the  sutures 
are  introduced  tier  upon  tier,  each  narrowing  the  denuded  area  and 
causing  the  edges  of  the  mucous  membrane  to  approach  each  other, 
till  finally  in  the  last  tier  these  edges  are  included. 

This  operation  may  be  combined  with  either  the  Saenger-Tait  01 
the  Emmet  on  the  perineum  and  posterior  vaginal  wall. 


Hypertrophy  of  the  Cervix. 

Give  the  varieties  and  etiology. 

Hypertrophy  of  the  cervix  may  involve  either  the  infra-vaginal 
or  supra-vaginal  portions.  Some  authorities  mention  hypertrophy 
of  the  intermediate  portion  of  the  cervix. 

Little  is  known  of  the  etiology. 

Hypertrophy  of  the  infra- vaginal  portion  is  usually  congenital. 

Hypertrophy  of  the  supra-vaginal  portion  usually  accompanies 
prolapse  of  the  uterus  or  vaginal  walls. 

What  are  the  physical  signs  and  symptoms  ? 

The  os  is  nearer  vulva  than  normal ;  it  may  even  project  beyond 
the  vulvar  opening. 

In  hypertrophy  of  the  infra-vaginal  portion,  the  cervix  is  long, 
usually  conical,  with  small  os  ;  the  vaginal  fornices  and  fundus  uteri 
are  in  their  normal  position.  If  the  cervix  protrudes  from  the 
vulva,  it  may  be  ulcerated,  from  friction. 

"In  hypertrophy  of  the  supra-vaginal  portion  both  anterior  and 
posterior  fornices  are  obliterated." 

' '  In  hypertrophy  of  the  intermediate  porti<  >n  the  posterior  f<  >rnix  re- 
mains, while  the  anterior  fornix  is  obliterated."    (Hart  and  Barbour. ) 

What  are  the  symptoms  ? 

The  symptoms  of  hypertrophy  of  the  infra-vaginal  portion  are 
chiefly  mechanical  : — 

Leucorrhoea,  from  vaginal  irritation. 

Discomfort  in  exercise. 

Sense  of  weight  in  the  pelvis. 

Sterility. 


STENOSIS   OF   THE   CERVIX. 


135 


The  symptoms  of  hypertrophy  of  the  supra-vaginal  portion  are 
those  of  the  prolapse  of  the  uterus  or  vaginal  walls,  which  it  usually 
accompanies. 

What  is  the  treatment  ? 

Amputation  of  the  cervix. 

There  are  several  methods  of  operation,  the  best  being  that  of 
Simon  and  Marckwald,  in  which  the  cervix  is  first  divided  by  a  trans- 
verse incision  into  an  anterior  and  posterior  lip  ;  a  wedge-shaped 

Fig.  37. 


Marckwald's  method  of  splitting  the  cervix  into  an  anterior  and  posterior  lip  and 
then  uniting  cervical  to  vaginal  mucous  membrane  {Schroeder). 

piece  is  then  removed  from  each  (see  Fig.  37),  and  the  flaps  of  each 
lip  are  brought  together  with  silver-wire  sutures. 


Stenosis  of  the  Cervix. 

What  is  the  etiology  ? 

It  may  be  either  congenital  or  acquired.  When  congenital,  it  is 
usually  associated  with  a  small  uterus.  Stenosis  of  the  external  os 
is  more  frequent  than  of  the  whole  canal. 

Acquired  stenosis  results  from  cicatrization  following  the  use  of 


136  ESSENTIALS  OF  GYNECOLOGY. 

too  strong  caustics,  endocervicitis,  or  a  too  complete  closure  of  the 
cervical  canal  in  a  trachelorrhaphy. 

What  are  the  symptoms  ? 

Dysrnenorrhoea  and  sterility. 

What  is  the  treatment  ? 

Dilate  the  cervix  "with  one  of  the  glove-stretcher  dilators  and 
maintain  the  dilatation  by  the  occasional  introduction  of  graduated 
sounds.  Outerbridge's  tubes  may  be  used  to  maintain  the  dila- 
tation. 

Laceration  of  the  Cervix. 

What  is  the  etiology  ? 

The  usual  cause  is  parturition  or  abortion  ;  it  occasionally  occurs 
as  a  result  of  mechanical  dilatation  of  the  cervix.  It  occurs  in  par- 
turition in  about  32  per  cent,  of  women  ;  especially  in  tedious,  pre- 
cipitate or  instrumental  deliveries.  It  is  predisposed  to  by  a  rigid 
os,  faulty  presentation  or  condition  of  the  foetus,  premature  rupture 
of  the  membranes  and  previous  disease  of  the  cervix. 

What  is  the  pathology  ? 

The  laceration  may  be — 

1.  Complete.    Penetrating  the  whole  thickness  of  the  cervix. 

2.  Partial.     Including  cervical  mucous  membrane,  but  not  ap- 

pearing on  the  vaginal  surface. 
It  may  be — 

(a)  Unilateral  (see  Fig.  38). 

(b)  Bilateral. 

(c)  Stellate  (see  Fig.  39). 

The  unilateral  laceration  is  most  apt  to  occur  in  the  line  of  the 
right  oblique  diameter  of  the  pelvis,  i.  e. ,  either  anteriorly  and  to 
the  left  or  posteriorly  and  to  the  right,  especially  the  former.  This 
is  supposed  to  arise  from  the  greater  frequency  of  the  first  position 
of  the  vertex. 

Bilateral  lacerations  are  usually  more  dangerous  than  those  of  the 
anterior  or  posterior  lip,  because  opening  up  the  cellular  tissue  of  the 
broad  ligaments. 

Stellate  lacerations  are  more  apt  to  be  superficial. 

If  the  surfaces  of  laceration  are  kept  clean,  more  or  less  union 


LACERATION   OF  THE  CERVIX. 


137 


Fig.  38. 


Single  Laceration.    The  flaps  are  held  apart  with  a  double  tenaculum  {Emmet). 


Fig.  39. 


Multiple  or  Stellate  Laceration  {Emmet). 


138  ESSENTIALS   OF  GYNAECOLOGY. 

will  occur.  Usually  there  is  partial  union,  with  eversion  and  pro- 
liferation of  the  cervical  mucous  membrane,  hyperplasia  of  the  con- 
nective tissue  and  proliferation  of  the  glandular  structure. 

What  are  the  complications  and  results  ? 

The  most  frequent  complications  are — 

1.  Cellulitis. 

2.  Peritonitis. 

3.  Endometritis,  especially  cervical  endometritis. 
The  common  results  are — 

1.  Subinvolution. 

2.  Chronic  metritis. 

3.  Displacements  of  the  uterus. 

4.  Sterility. 

5.  Abortion. 

6.  Epithelioma. 

If  the  laceration  has  extended  through  the  anterior  fornix,  a  vesico- 
vaginal or  vesico-uterine  fistula  may  remain. 

What  are  the  symptoms  ? 

They  are  chiefly  those  of  the  complications ;  especially  cellulitis 
and  peritonitis.  The  patient  usually  complains  of  a  feeling  of  weight 
in  the  pelvis ;  leucorrhoea,  disturbances  of  menstruation,  especially 
menorrhagia  ;  sterility ;  neuralgia  and  various  reflex  neuroses.  At 
the  time  of  the  laceration  there  may  be  considerable  hemorrhage. 

What  are  the  physical  signs  ? 

On  making  a  vaginal  examination  the  cervix  usually  feels  enlarged 
and  more  sensitive  than  usual ;  the  fissure  can,  as  a  rule,  be  readily 
detected  ;  also,  if  present,  the  eversion  of  the  cervical  mucous 
membrane,  which  usually  feels  velvety,  often  granular  or  cystic. 
Sometimes  the  eversion  is  so  extreme  that  one  does  not  notice  the 
fissure,  simply  feeling  the  velvety  or  granular  area  about  the  os. 
The  latter  may  be  so  patulous  as  to  admit  the  finger.  On  making 
the  bimanual  examination  the  uterus  is  often  found  enlarged  as  a 
whole  ;  cicatrices  may  be  felt  extending  from  the  laceration  into  one 
of  the  vaginal  fornices.  With  the  aid  of  the  speculum  one  sees  the 
erosion  on  one  side  of  or  surrounding  the  os,  and  by  drawing  the 
edges  of  the  laceration  together  with  tenacula  the  extent  of  the  tear 


LACERATION  OF  THE  CERVIX.  139 

is  visible.     Without  this  latter  procedure,  one  is  greatly  deceived, 

in  some  cases,  as  to  the  degree  of  the  injury. 

What  is  the  treatment  ? 

Unless  there  is  hemorrhage,  immediate  treatment  is  seldom  re- 
sorted to.  If  the  hemorrhage  is  severe,  a  silver-wire  suture  may  be 
inserted  and  twisted  up.  Hot- water  vaginal  injections  will  usually 
obviate  the  necessity  of  the  suture. 

The  treatment  after  the  puerperium  is  as  follows :  The  complica- 
tions, if  present,  are  first  treated,  especially  peritonitis  or  cellulitis,  by 
counter-irritation,  hot-water  vaginal  douches,  glycerine  tampons,  etc. 

The  cervical  endometritis  is  treated  by  pricking  the  cysts,  if  pres- 
ent, and  applying  to  the  cervical  mucous  membrane  carbolic  acid  or 
iodized  phenol.  The  corporeal  endometritis  is  treated  by  the  cu- 
rette, if  necessary,  and  applications  as  in  cervical  endometritis. 

The  growth  of  the  squamous  epithelium  over  the  erosions  is  stimu- 
lated by  astringent  applications,  especially  pyroligneous  acid.  Under 
the  above  procedures  the  uterus  often  returns  to  its  normal  size,  and 
the  symptoms  associated  with  the  laceration  disappear. 

If  the  symptoms  continue  after  the  foregoing  treatment,  and 
neither  peritonitis  nor  cellulitis  are  present,  Emmet's  operation  of 
trachelorrhaphy  is  indicated. 

Describe  briefly  the  operation  trachelorrhaphy. 

The  patient  is  given  an  antiseptic  vaginal  douche,  is  anaesthetized 
and  placed  in  Sims'  position,  with  Kelly' s  perineal  pad  under  the  hips. 
A  Sims'  speculum  is  introduced,  the  anterior  lip  of  the  cervix  seized 
with  a  volsella  and  the  uterus  drawn  down  and  held  by  an  assistant. 

The  edges  of  the  laceration  are  now  pared  with  scissors  or  knife, 
giving  the  denuded  area  seen  in  Fig.  40,  and  leaving  enough  mucous 
membrane  in  the  centre  for  the  cervical  canal.  Care  should  be  taken 
to  excise  the  plug  of  cicatricial  tissue  at  the  angle  of  the  laceration. 
The  parts  are  now  irrigated  with  an  antiseptic  solution,  and  the  su- 
tures of  silver  wire  introduced,  usually  3-4  on  a  side,  beginning  at 
the  upper  angle.  Each  is  passed  from  the  surface  of  the  vaginal 
portion,  through  the  thickness  of  one  lip,  emerging  in  the  edge  of 
the  undenuded  mucous  membrane  ;  thence  is  passed  into  the  edge 
of  the  undenuded  mucous  membrane  of  the  other  lip,  through  the 
lip's  substance,  and  emerges  on  the  surface  of  the  vaginal  portion. 


140 


ESSENTIALS  OF  GYNAECOLOGY. 


The  other  sutures  of  the  same  side  are  introduced  in  a  similar  man 
ner,  care  being  taken  to  bring  the  parts  into  close  apposition  and 
leave  no  pockets.     If  the  laceration  is  bilateral,  the  suturing  of  the 
other  side  is  conducted  in  the  same  manner.     The  parts  are  again 
irrigated  ;  the  sutures  twisted  up,  left  ?-f  inch  long  and  bent  down 

Fig.  40. 


Extent  of  Denuded  Surface  and  Course  of  Sutures  according  to  Eramet  (Emmet). 
The  sutures  are  passed  in  order  1,  2,  3,  4;  the  course  of  suture  4  alone  is  indicated 

by  letters  a,  b,  c,  d. 

on  the  cervix.  Iodoform  is  insufflated  against  the  cervix,  and  a  tam- 
pon of  iodoform  gauze  introduced.  The  sutures  are  left  8-10  days ; 
they  may  be  left  longer  if  the  perineum  is  repaired  at  the  time  of  the 
trachelorrhaphy. 

Endometritis. 

Define  and  give  the  varieties. 

Endometritis  is  an  inflammation  of  the  lining  membrane  of  the 
uterus ;  it  may  be  either  acute  or  chronic.  Acute  endometritis 
usually  involves  both  cervix  and  body. 


ENDOMETRITIS.  141 

The  chronic  is  often  confined  to  either  cervix  or  body,  and  called 
in  the  former  case  cervical  endometritis,  endocervicitis,  or  chronic 
cervical  catarrh  ;  in  the  latter  case,  corporeal  endometritis. 

Occasionally,  chronic  endometritis  affects  the  whole  uterus. 

Acute  Endometritis. 
What  is  the  etiology  ? 

Before  puberty  it  is  rare.  The  most  common  causes  are  the  fol- 
lowing : — 

1.  Traumatism  and  sepsis,  especially  from  dirty  instruments. 

2.  Gonorrhoea. 

3.  Catching  cold  during  menstruation. 

4.  Excessive  coitus  near  menstruation. 

5.  Severe  types  of  the  exanthemata. 

6.  It  is  one  of  the  lesions  in  puerperal  septicaemia. 

What  is  the  pathology  ? 

Usually  the  endometrium  of  both  body  and  cervix  is  involved, 
but  the  former  more  than  the  latter.  The  mucous  membrane  is 
swollen  and  softened  ;  extravasations  of  blood  into  it  occur  ;  the  epi- 
thelium is  destroyed  and  desquamated.  The  secretion  is  first 
serous,  later  purulent,  perhaps  bloody. 

What  are  the  complications  ? 

The  most  common  are — 

Vaginitis. 
Urethritis. 
Salpingitis. 
Peiitonitis. 

What  are  the  physical  signs  ? 

The  cervix  is  enlarged,  soft  and  slightly  sensitive  ;  the  endome- 
trium is  veiy  sensitive  to  the  sound  or  probe,  and  these  should  be 
avoided.  There  is  often  an  erosion  about  the  os,  which  is  usually 
filled  with  a  ropy  secretion.  The  cervix  sometimes  looks  and  feels 
like  that  of  early  pregnancy. 

What  are  the  symptoms  ? 

The  characteristic  symptom  is  the  discharge,  which  is  first  watery, 
then  creamy.  There  is  usually  a  slight  rise  of  temperature  and  a 
dull  pain  in  back  and  pelvis. 


142  ESSENTIALS   OF  GYNAECOLOGY. 

If  gonorrhoea  was  a  factor  in  the  etiology  the  symptoms  are  usu- 
ally more  marked.  Sometimes  vesical  aud  rectal  irritability  are 
present. 

What  is  the  treatment  ? 

Put  the  patient  to  bed  ;  give  light  diet ;  keep  the  bowels  open  ; 
give  a  little  opium  if  the  pain  requires  it ;  apply  hot  fomentations 
over  the  hypogastrium.  When  the  secretion  becomes  purulent, 
administer  warm-water  douches  ;  it  is  well  to  add  borax  to  the  latter, 

3j-Oj. 

Chronic  Endometritis. 

What  are  the  varieties  ? 

(a)  Chronic  cervical  endometritis. 

(b)  Chronic  corporeal  endometritis. 

A.    Chronic  Cervical  Endometritis. 

What  are  the  synonyms  ? 

Chronic  cervical  catarrh  and  endocervicitis. 

What  is  the  etiology  ? 

Chronic  cervical  endometritis  is  predisposed  to  by  any  low  state  of 
the  system,  from  whatever  cause  produced. 

The  most  common  exciting  causes  are — 
(<()  Laceration  of  the  cervix. 

(b)  Extension  upward  of  a  vaginitis. 

(c)  Extension  downward  of  a  corporeal  endometritis. 

(d)  Displacements  of  the  uterus,  especially  flexions. 

(e)  Stenosis  of  the  cervix. 

(/)  Traumatism,  especially  septic. 

{(/)  Excessive  coitus. 

(/<)    Catching  cold  during  menstruation. 

What  is  the  pathology  ? 

In  mild  cases  the  mucous  membrane  alone  may  be  involved,  but 
•  it ten  more  or  less  of  the  substance  of  the  cervix  is  affected.  In  a 
well-marked  case  the  epithelium,  glands  and  interstitial  tissue  are 
•ill  involved  in  the  change. 

The  cylindrical  epithelium  of  the  canal  proliferates  and  replaces 
the  squamous  epithelium  on  the  vaginal  portion  of  the  cervix,   This 


ENDOMETRITIS.  143 

;fl  especially  true  where  the  cervix  is  lacerated,  and  the  cervical 
mucous  membrane  is  everted. 

The  glands  of  the  cervix  are  hypertrophied  and  proliferated,  and 
in  addition  to  this,  according  to  Huge  and  Yeit,  the  surface  of  the 
mucous  membrane  is  thrown  into  numerous  folds,  producing  gland- 
ular recesses  and  processes. 

The  connective  tissue  of  the  cervix  is  also  increased. 

The  reddened  areas  about  the  os,  where  cylindrical  epithelium 
has  replaced  the  squamous,  and  the  glandular  structure  has  increased, 
are  called  erosions,  sometimes  wrongly  spoken  of  as  ' ;  ulcerations. ' ' 

What  are  the  varieties  of  erosion  ? 

According  to  the  depth  of  the  recesses  in  the  folds  of  the  mucous 
membrane  covered  with  cylindrical  epithelium,  Huge  and  Veit  dis- 
tinguish three  varieties  : — 

1.  The  simple  erosion. 

2.  The  papillary. 

3.  The  follicular. 

When  the  mouths  of  these  recesses  become  occluded,  it  forms 
the  cystic  erosion.  These  cysts  may  enlarge  and  extend  toward 
the  surface  of  the  cervix  where  it  is  covered  with  squamous 
epithelium. 

What  are  the  physical  signs  of  chronic  cervical  endome- 
tritis? 

In  nulliparae  the  cervix  may  feel  normal,  save  a  little  swollen  and 
seusitive  ;  sometimes  the  neighborhood  of  the  os  has  a  granular  or 
velvety  feel. 

In  multiparas,  especially  where  the  cervix  is  lacerated,  the  gran- 
ular area  about  the  os  is  larger,  and  small  cysts  in  greater  or  less 
numbers  can  usually  be  felt. 

What  are  the  symptoms  ? 

The  characteristic  symptom  is  the  leucorrhcea ;  this  may  irritate 
the  vulva,  causing  pruritus. 

Pain  in  the  back  and  loins,  especially  on  exertion,  is  usually  present, 
but  may  be  slight. 

Other  symptoms  are  disturbances  of  menstruation,  especially  Men- 
orrhagia, sterility  and  reflex  neuroses. 


144 


ESSENTIALS   OF  GYNAECOLOGY. 


What  is  the  treatment  ? 

Attend  to  the  general  health  and  remove,  as  far  as  possible,  the 
causes  of  the  endometritis. 

In  mild  cases,  especially  in  nulliparae,  use  hot-water  vaginal 
douches  containing  an  astringent,  as  sulphate  of  zinc  3j-Oj. 

If  more  severe,  remove  the  ropy  mucus  from  the  canal  with  a 
large-mouthed  syringe  and  apply  iodized  phenol. 

When  the  cervix  is  cystic  or  much  congested,  prick  the  cysts  or 
scarify  the  cervix. 

Fig.  42. 


Schroeder's  excision  of  the  cervical  mucous  membrane  in  cervical  catarrh. 
Fig.  41.  Line  of  incision  in  mucous  mem-    Fig.  42.  Mucous  membrane  excised  and 
brane.  flap  be  turned  in  on  ab  (Schrotder). 

If  the  above  treatment  fails,  thoroughly  curette  the  cervix,  dilat- 
ing if  necessary,  and  apply  iodized  phenol. 

Schroeder's  operation  consists  in  dividing  the  cervix  into  an  ante- 
rior and  posterior  lip,  excising  the  mucous  membrane  by  a  V-shaped 
incision  (see  Fig.  41),  and  turning  in  and  uniting  the  lips  as  seen  in 
Fig.  42. 

When  the  cervix  is  badly  lacerated  trachelorrhaphy  is  indicated. 

B.   Chronic  Corporeal  Endometritis. 

What  is  the  etiology  ? 

It  sometimes  follows  the  acute,  more  often  begins  as  chronic. 

The  most  common  causes  are — 

1.  Parturition,  especially  when  the  seciradines  are  not  thoroughly 
removed. 


ENDOMETRITIS.  145 

2.  Displacements. 

3.  Traumatism,  especially  septic. 

4.  Tumors,  especially  fibroids  and  polypi. 

5.  Excessive  coitus. 

6.  Extension  of  inflammation  from  the  cervix. 

7.  Chronic  metritis. 

What  is  the  pathology  ? 

The  mucous  membrane  is  diseased  in  one  or  all  of  its  elements. 

1.  The  glands  maybe  chiefly  affected,  beiDg  hypertrophied,  and 
new  glandular  tissue  may  be  developed  by  mfoldings  of  the  mucous 
membrane.     The  glands  may  become  cystic  or  may  atrophy. 

2.  The  cells  and  intercellular  substance  may  be  increased,  and 
constitute  the  characteristic  change. 

3.  The  blood  vessels  may  be  dilated  and  increased. 

4.  All  the  elements  may  be  involved  :  the  glands,  interstitial  tissue 
and  blood  vessels  may  all  be  increased. 

The  hypertrophied  mucous  membrane  may  assume  polypoid  or 
fungous  shapes,  giving  rise  to  the  names  "uterine  fungosities" 
and  ' '  villous  endometritis. ' '  This  is  a  result  of  the  preceding  forms, 
usually  the  mixed,  where  all  parts  are  involved  ;  it  is  especially  apt 
to  arise  from  the  inflammation  started  by  retained  secundines ;  it 
causes  more  hemorrhage  than  the  other  forms. 

Chronic  cervical  endometritis  and  chronic  corporeal  endometritis 
are  often  associated. 

What  are  the  symptoms  of  chronic  corporeal  endometritis  ? 

(a)  Leucorrhcea. 

(h)  Menstrual  disturbances,  especially  menorrhagia. 

(c)  Dysnienorrhoea. 

(d)  Pain  in  back  and  pelvic  region. 

(e)  Sterility. 
(/)  Abortion. 

{g)  Reflex  neuroses. 

What  are  the  physical  signs  ? 

On  bimanual  examination  the  uterus  is  usually  found  more  or  less 
enlarged  ;  perhaps  a  little  tender. 
10 


146  ESSENTIALS   OF  GYNECOLOGY. 

The  sound,  on  introduction,  shows  the  cavity  enlarged,  and  usually 
detects  irregularities  in  its  mucous  membrane  ;  it  frequently  causes 
slight  bleeding. 

What  are  common  complications  ? 

Metritis. 

Salpingitis. 

Peritonitis. 

Displacements. 

Vaginitis. 

What  is  the  treatment? 

1.  Prophylactic. — Be  careful  that  the  uterus  is  thoroughly  emp- 
tied after  labor  or  abortion.  Avoid  exposure  during  menstruation. 
Observe  strict  cleanliness  and  antisepsis  in  the  use  of  uterine  in- 
struments. 

2.  When  no  Irregularities  of  the  Endometrium  are  Detected. — 
Make  occasional  applications  of  iodized  phenol  to  the  endometrium. 
Administer  internally,  three  or  four  times  a  day,  fifteen  drops  each 
of  the  fluid  extracts  of  ergot  and  hydrastis  canadensis. 

3.  When  Irregularities  of  the  Endometrium  are  Detected. — If  no 
acute  inflammation  is  present  in  the  neighborhood,  curette  the 
uterus  under  antiseptic  precautions,  dilating  the  cervix  previously  if 
necessary  ;  wash  out  the  uterus  with  an  antiseptic  solution,  making 
use  of  a  double-current  catheter ;  then  apply  to  the  endometrium 
iodized  phenol,  and  administer  internally  ergot  and  hydrastis,  as  be- 
fore. The  curetting,  if  thorough,  is  best  done  under  anaesthesia. 
It  is  well  to  confine  the  patient  to  bed  for  a  few  days,  and  occasional 
applications  of  iodized  phenol  to  the  endometrium  may  be  necessary. 


Metritis. 

Describe  and  give  the  varieties. 

Metritis  is  an  inflammation  of  the  parenchyma  of  the  uterus,  as 
distinguished  from  that  of  its  mucous  lining  or  serous  covering. 
The  two  varieties  are  the  acute  and  chronic. 


metritis.  147 

Acute  Metritis. 

What  is  the  etiology? 

Acute  metritis  rarely  if  ever  exists  as  an  independent  condition  ; 
it  is  almost  always  associated  with  an  endometritis  or  peritonitis ; 
especially  the  former. 

The  chief  causes  are — 

1.  Acute  endometritis. 

2.  Septic  absorption  during  labor,  abortion  or  operation. 

3.  Acute  peritonitis. 

Acute  metritis  occasionally  arises  from  exposure  to  cold  during 
menstruation,  gonorrhoea  or  sexual  excess,  but  these  usually  first 
produce  endometritis,  secondarily  metritis. 

What  is  the  pathology? 

The  uterus  is  enlarged,  especially  antero-posteriorly,  infiltrated 
with  serum,  soft  and  tender.  The  endometrium  is  also  thickened 
and  congested.  The  peritoneal  investment  is  often  covered  with 
lymph.  "Microscopically  the  muscular  bundles  are  infiltrated  with 
pus  corpuscles ' '  (Hart  and  Barbour).  Circumscribed  abscesses  oc- 
casionally, though  rarely,  occur  in  the  uterine  walls ;  they  are  some- 
times absorbed,  sometimes  become  encapsulated  and  cheesy,  and 
sometimes  empty  into  the  uterus,  bladder,  rectum,  vagina,  intestines, 
peritoneum  or  through  the  abdominal  walls.  * 

Acute  metritis  may  resolve  at  the  end  of  a  week,  but  often  passes 
into  the  chronic  form. 

What  are  the  symptoms? 

They  usually  resemble  those  of  acute  endometritis,  but  are  more 
severe.  The  disease  is  often  ushered  in  with  a  rigor  ;  temperature 
and  pulse  rise  ;  there  is  pain  in  the  hypogastrium  and  in  pelvis. 
The  uterus  is  very  tender  on  pressure  ;  there  is  nausea,  usually  vesi- 
cal and  rectal  tenesmus,  and  menstruation,  as  a  rule,  is  disturbed, 
sometimes  suppressed  ;  more  often  menorrhagia  is  present. 

What  is  the  treatment? 

If  due  to  sepsis,  try  to  remove  the  cause ;  giving,  if  necessary, 
intrauterine  injections  of  carbolic  (1-100)  or  bichloride  (1-5000). 
Keep  the  patient  quiet  in  bed,  apply  poultices  or  turpentine  stupes 
to  the  hypogastrium  ;  if  temperature  very  high,  use  the  ice  coil. 


148  ESSENTIALS   OF   GYNECOLOGY. 

Keep  the  bowels  regular  by  enemata ;  if  pain  very  severe,  allow 
opium  by  suppository.  Later,  employ  long,  hot-water  douches  and 
glycerine  tainpons. 

Chronic  Metritis. 

What  are  common  synonyms? 

Areolar  hyperplasia  (Thomas).     Chronic  parenchymatous  inflam 
mation  of  the  womb  (Scanzoni).     Diffuse  interstitial  metritis  (Noeg- 
gerath). 

What  is  the  etiology? 

According  to  Hart  and  Barbour,  the  causes  may  be  divided  as 
follows : — 

(a)  Causes  which  operate  through  interference  with  the  normal 
involution  of  the  puerperal  uterus. 

(b)  Causes  which  operate  through  the  production  of  repeated  or 
protracted  congestion  of  the  uterus. 

(A)  Frequent  causes  of  subinvolution  are — 

1.  Retained  sec-undines. 

2.  Laceration  of  the  cervix. 

3.  Pelvic  inflammation  following  parturition. 

4.  Rising  too  soon  after  parturition. 

5.  Non-lactation. 

6.  Repeated  miscarriages. 

(B)  Causing  repeated  or  protracted  congestion  are  the  following — 

1.  Chronic  endometritis. 

2.  Displacement  of  the  uterus. 

3.  Tumors  near  the  uterus. 

4.  Chronic  pulmonary,  cardiac,  hepatic  or  nephritic  disease. 

5.  Excessive  coitus. 

Chronic  metritis  sometimes  follows  the  acute  but  usually  begins  as 
chronic. 

What  is  the  pathology  ? 

The  pathological  changes  may  be  divided  into  three  stages — 

1.  Hy  perse  in  ie. 

2.  Hyperplastic. 

3.  Sclerotic. 

In  the  first  or  hyperaBmic  stage,  the  uterus  is  enlarged,  soft,  tender, 
and  contains  more  blood  than  normal. 


METRITIS.  149 

In  the  second  or  hyperplastic  stage,  there  is  an  increase  of  the 
intermuscular  connective  tissue,  with  or  without  a  slight  increase  of 
the  muscular  tissue.  The  vascularity  is  decreased  by  the  growth  of 
connective  tissue  around  and  compressing  the  blood  vessels. 

The  third,  or  sclerotic  stage  is  a  result  of  the  former,  the 
uterus  becoming  more  dense,  less  and  less  vascular  and  finally 
atrophied. 

What  are  the  symptoms  ? 

Most  of  the  symptoms  are  either  due  to  the  increased  size  of  the 
uterus  or  to  the  complicating  endometritis.  The  symptoms  usually 
date  from  parturition  or  abortion.     The  following  are  common — 

A  feeling  of  weight  in  the  pelvis. 

Pains  radiating  to  the  back,  limbs  and  different  parts  of  the  body. 

Irritability  of  bladder  and  rectum. 

Leucorrhoea. 

Menstrual  disturbances,  especially  nienorrhagia,  due  to  the  endo- 
metritis. 

Abortion  in  the  early  stages. 

Sterility,  later. 

Reflex  neuroses. 

What  are  the  physical  signs  ? 

The  uterus  in  the  early  stages  is  uniformly  enlarged,  soft  and 
tender  ;  later  harder,  and  in  the  late  stages  irregularities  of  shape 
may  be  detected.  The  canal  is  enlarged  in  all  its  dimensions  and  the 
sound  passes  easily.  The  os  is  usually  patulous  ;  the  cervix  may  be 
large  and  nodular. 

From  what  must  you  differentiate  chronic  metritis  ? 

From  early  pregnancy,  small  fibroid  tumors  and  malignant  disease. 

How  would  you  differentiate  chronic  metritis  from  early 
pregnancy. 

In  early  pregnancy  the  enlargement  of  the  uterus  is  more  in  the 
antero-posterior  diameter  ;  in  metritis  the  enlargement  is  more  uni- 
form. 

The  uterus  is  tender  in  metritis,  usually  not  in  pregnancy. 

In  pregnancy,  also,  the  cessation  of  menstruation  and  softening  of 
the  cervix  usually  aid  us  in  the  diagnosis. 


150  ESSENTIALS  OF  GYNECOLOGY. 

How  would  you  differentiate  chronic  metritis  from  fibroid 
tumors  ? 

In  small  fibroid  tumors  of  the  uterus,  the  irregular  shape  is  con- 
trasted with  the  more  uniform  enlargement  in  metritis.  The  uterine 
cavity  is  usually  more  spacious  in  chronic  metritis  than  when  fibroids 
are  present. 

The  sound  will  often  aid  in  the  diagnosis.  In  some  cases  it  is 
justifiable  to  dilate  the  cervix  and  introduce  the  finger  to  determine 
the  presence  or  absence  of  a  submucous  fibroid  tumor. 

How  would  you  differentiate  chronic  metritis  from  malignant 
disease  of  the  uterus  1 

Malignant  disease  of  the  uterus  is  more  apt  to  occur  late  in  life ; 
metritis  earlier. 

Cachexia  and  menorrhagia  are  more  marked  in  the  former  than  in 
the  latter. 

What  are  common  complications  of  chronic  metritis  ? 

(a)   Chronic  endometritis. 
(/>)    Salpingitis. 

(c)  Peritonitis. 

(d)  Ovaritis. 

(e)  Vaginitis. 

(/)  Displacements. 

What  is  the  treatment  of  chronic  metritis  ? 

1.  Prophylactic. — Care  during  and  after  confinement. 

2.  Curative. — 

First  treat  the  complications,  if  present,  especially  endometritis 
and  displacements,  in  the  usual  manner.  Attend  to  the  general 
health,  bowels,  exercise,  etc.  Let  the  patient  rest  a  part  of  each 
day,  especially  at  menstruation ;  limit  coitus.  Weir  Mitchell's 
treatment  of  rest,  over-feeding  and  massage  is  sometimes  of  value. 

Local  treatment. — Prolonged  hot-water  vaginal  douches;  glycer- 
ine or  boroglyceridc  tampons ;  tincture  of  iodine  to  cervix  and  fornices; 
of  the  vagina  ;  scarification  of  the  cervix  with  Buttle' s  spear. 

Emmet's  operation  of  trachelorrhaphy,  or  amputation  of  the 
cervix  by  the  Simon  and  Marckwald  method  is  sometimes  indicated. 

Apostoli  strongly  recommends  the  use  of  galvanism. 


ATROPHY  OF  THE  UTERUS.  151 


Atrophy  of  the  Uterus. 

What  is  the  etiology  ? 

It  is  the  natural  condition  after  the  menopause,  and  is  produced 
artificially  by  the  removal  of  ovaries  and  tubes.  It  is  sometimes 
associated  with  phthisis  and  other  exhausting  diseases.  It  occurs  as 
a  superin volution  after  childbirth,  especially  as  a  result  of  metritis, 
peritonitis,  ovaritis  or  salpingitis.  This  superinvolution  is  the  variety 
of  most  importance. 

What  are  the  symptoms  ? 

Amenorrhoea. 
Sterility. 
Reflex  neuroses. 

What  are  the  physical  signs  ? 

The  uterus  is  small,  both  in  body  and  cervix,  and  the  canal  is 
shortened. 

What  is  the  treatment  ? 

Attend  to  the  general  health. 

Before  the  menopause,  galvanism  of  the  uterus  and  ovaries  may 
be  tried. 
The  treatment  is  generally  unsatisfactory. 

Fibroid  Tumors  of  the  Uterus. 

What  are  common  synonyms  ? 

Eibro-myomata  and  myomata.  Strictly  speaking,  fibro-myomata 
is  the  more  correct  designation,  as  the  tumors  are  composed  of  both 
fibrous  and  muscular  tissue. 

What  is  the  etiology  ? 

Little  is  known  of  the  cause  of  fibroids.  They  are  much  more 
common  in  the  African  than  in  the  white  race  ;  are  most  frequently 
found  between  the  ages  30-45,  and  are  said  to  be  more  common  in 
married  than  in  unmarried  women.  They  rarely,  if  ever,  begin  be- 
fore puberty,  and  never  after  the  menopause. 

What  is  their  structure  ? 

Fibroids,  or  fibro-myomata  of  the  uterus,  are  tumors  composed  of 


152 


ESSENTIALS   OF  CxYN^COLOGY. 


both  fibrous  and  muscular  tissue,  either  of  which  may  predominate 
over  the  other.     The  fibrous  tissue  is  usually  in  excess. 

Those  composed  chiefly  of  fibrous  tissue  are  usually  more  or  less 
encapsulated  and  of  slow  growth. 

Those  composed  chiefly  of  muscular  tissue  are  rare,  not  encapsu- 
lated, and  are  of  rapid  growth. 

Fig.  43. 


im.  Interstitial  fibroids. 

sm.  Submucous.    (Schroeder.) 


What  are  their  situations  ? 

They  are  much  more  frequent  in  the  I  tody  of  the  uterus  than  in  the 
cervix.  They  are  most  often  found  on  the  posterior  wall,  next  in 
frequency  OE  the  anterior  wall,  rarely  on  the;  lateral  walls.  The  soft, 
rapidly-growing  fibroids  arc  more  frequent  in  the  fundus. 

The  tumors  always  begin  in  the  substance  of  the  uterine  walls  ; 


FIBROID  TUMORS   OF  THE  UTERUS. 


153 


they  may  continue  their  growth  there  ;  may  extend  into  the  uterine 

cavity,  lifting  up  the  mucous  membrane,  or  outward,  lifting  up  the 

peritoneum.      Hence  the   three 

•    ■•  Fig.  44. 

varieties  : — 

1.  Interstitial. 

2.  Submucous. 

3.  Subperitoneal. 


Describe  the  three  varieties. 

The  interstitial  or  intramural 
fibroids  (see  Fig.  43),  are  usually 
multiple  and  are  situated  in  the 
substance  of  the  uterine  wall.  The 
submucous  fibroid  (see  Fig.  44), 
may  be  either  sessile  or  attached 
by  a  long  pedicle.  In  the  latter 
case  it  is  called  a  fibrous  polypus. 

The  subperitoneal  or  subserous 
fibroids  (see  Figs.  45  and  46), 
are  often  multiple  ;  may  be  ses- 
sile or  pedunculated  ;  may  grow 
upward  into  the  abdominal  cavity 
and  draw  uterus  up,  or  grow  downward  into  the  pelvis,  and  perhaps 

Fig.  45. 


Submucous  fibroid.    (Schroeder.) 


Subperitoneal  Fibroid. 

become  incarcerated.  They  may  form  adhesions  with  other  organs, 
get  their  nutrition  through  the  adhesions  and  become  detached  from 
the  uterus. 


154 


ESSENTIALS   OF  GYNAECOLOGY. 


Fig.  46. 


What  changes  may  occur  in  fibroids  ? 

1.  They  may  undergo  softening  due  to  oedema  or  myxomatous 
degeneration,  rarely  fatty  degeneration.  By  this  softening  fibro- 
cysts  may  be  formed. 

2.  They  may  undergo  hardening,  due  to  (<t)  atrophy,  especially 
after  the  menopause,  or  removal  of  ovaries  and  tubes.  The  mus- 
cular tissue  degenerates,  and  the  fibrous  tissue  contracts,  (h)  Calci- 
f  cation,  with  the  deposit  of  lime  salts,  beginning  usually  in  the  centre, 

sometimes  at  the  periphery. 

3.  They  may  suppurate.  This 
occurs  most  often  in  submucous 
fibroids,  especially  after  instru- 
mental traumatism  ;  rarely  in  the 
subperitoneal  variety  after  tor- 
sion of  the  pedicle. 

4.  Submucous  fibroids  may 
become  more  and  more  peduncu- 
lated, forming  polypi.  They  are 
sometimes  extruded  from  the 
uterus.  Sometimes  the  capsule 
ruptures,  and  spontaneous  enu- 
cleation occurs. 


What  changes  occur  in  the 
uterus  ? 

The  muscular  wall  hypertro- 
phies, especially  in  the  submu- 
cous or  interstitial  varieties.  The 
mucous  membrane  also  hyper- 
trophies, both  in  glands  and  connective  tissue.  Over  the  tumor  the 
mucous  membrane  sometimes  ulcerates. 

Changes  in  the  position  of  the  uterus  are  often  produced  : — 

1 .  It  may  be  drawn  up  into  the  abdomen. 

2.  It  may  be  prolapsed. 

3.  It  may  be  inverted,  especially  from  submucous  fibroids  attached 
to  the  fundus. 

Describe  briefly  fibroids  of  the  cervix. 

They,  too,  may  be  either  interstitial,  submucous  or  subperitoneal ; 
they  are  usually  hard  and  single. 


Subperitoneal  Fibroid. 


FIBROID  TUMORS   OF  THE  UTERUS.  155 

The  subperitoneal  often  grow  out  between  the  folds  of  the  broad 
ligament. 

The  submucous  and  interstitial  are  apt  to  become  pedunculated 
and  form  polypi.  The  interstitial  fibroid  of  the  cervix  is  sometimes 
mistaken  for  inversion  of  the  uterus. 

What  are  the  symptoms  of  fibroid  tumors  of  the  uterus  ? 

1 .  Hemorrhage.  — First,  menorrhagia,  later  metrorrhagia  ;  this 
occurs  especially  in  the  submucous  variety. 

2.  Pain. — (a)  Dysmenorrhea,  chiefly  in  the  submucous  variety. 

(b)  Pain  due   to  pressure  on  the  pelvic  nerves  or  to 
peritonitis  around  the  tumor. 

3.  Symptoms  due  to  pressure  : — 

On  bladder,  causing  : — 

Irritability. 

Retention. 

Cystitis. 
On  urethra,  causing: — Difficulty  in  micturition. 

Perhaps  retention. 
On  ureter,  causing  : — Hydronephrosis. 
On  rectum,  causing: — Constipation. 

Sometimes  tenesmus. 

Rarely  complete  obstruction. 
On  pelvic  nerves,  causing  : — 

Neuralgia. 

Numbness. 
On  veins,  causing  : —  Varicosities. 

4.  Sterility. 

5.  Abortion. 

What  are  the  physical  signs  ? 

Except  in  the  case  of  some  subperitoneal  fibroids,  the  uterus  is 
enlarged. 

If  within  reach,  a  tumor  is  felt,  harder  than  the  muscular  sub- 
stance of  the  uterus,  and  movable  with  the  uterus  unless  it  is  attached 
with  a  very  long  pedicle. 

If  it  is  a  small  fibroid  in  the  cervix  it  may  bulge  into  the  vagina  and 
resemble  inversion  of  the  uterus. 

If  it  is  a  submucous  fibroid,  high  up  in  the  uterus,  the  sound  may 


156  ESSENTIALS   OF  GYNECOLOGY. 

detect  it.  but  often  it  is  necessary  to  dilate  the  cervix  and  introduce 
the  finger. 

If  it  is  subperitoneal  and  on  the  anterior  wall,  a  hard  mass  is  felt  in 
the  anterior  fornix  moving  with  the  uterus  ;  the  fundus  may  be  felt 
above  and  behind  it,  and  the  sound  on  introduction  does  not  pass  into  it. 

If  on  the  posterior  wall,  a  hard  mass  is  felt  in  the  posterior  fornix  ; 
the  bimanual  shows  fundus  in  front  of  it,  and  the  sound  passes  in 
front  of  it. 

If  it  is  a  large  fibroid  extending  into  the  abdomen,  it  is  flat  on  per- 
cussion unless  intestine  overlies  it ;  auscultation  may  detect  the  ute- 
rine souffle,  especially  at  the  sides,  and  the  mass  seems  to  belong  to 
the  uterus. 

From  what  must  you  differentiate  a  fibroid  tumor  of  the  uterus  ? 

Chronic  metritis. 
Flexions  of  the  uterus. 
Pregnancy. 
Ovarian  cyst. 
Extra-uterine  gestation. 
Pelvic  haematocele. 
Inflammatory  deposits. 
Inversion  of  the  uterus. 

How  would  you  differentiate  a  small  fibroid  tumor  from 
chronic  metritis  ? 

Small  Fibroid  vs.  Chronic  Metritis. 

Enlargement  not  uniform,  usually      Enlargement  uniform. 

hard  irregularities. 
Less  sensitive.  More  sensitive. 

Os  usually  unaffected.  Os  usually  everted. 

Both  conditions  may  co-exist, 
The  differential  diagnoses  between  fibroids  and  flexions   of  the 
uterus  have  already  been  given  (see  page  1 1 4,  Fig.  23). 

Kow  would  you  differentiate  a  fibroid  tumor  from  pregnancy  ? 

Fihroid  Tumor  vs.  Prrf/iKinn/. 

Menstruation  continues;  usually      Amenorrhea  is  the  rule. 

increased. 
Cervix  not  softened.  Cervix  softened. 


FIBROID  TUMORS   OF  THE  UTERUS. 


157 


Later. 

Absence  of  positive  signs  of  preg-      Positive  signs  present, 
nancy. 

How  would  you  differentiate  a  fibroid  tumor  from  an  ovariar* 
cyst? 

Fibroid  Tumor  vs.  Ovarian  Cyst. 


Hard  and  firm. 

More  intimately  connected  with 

uterus. 
More  central. 
Menorrhagia  common. 


Soft  and  elastic. 

Less  intimately  connected  with 
uterus. 

More  lateral. 

Menstruation  normal  or  irregu- 
lar ;  menorrhagia  rare. 


How  would  you  differentiate  a  fibroid  tumor  from  an  extra 
uterine  gestation  ? 

Fibroid  Tumor  vs. 

No  menstrual  period  skipped. 


Grows  less  rapidly. 

More  central. 

More  intimately  connected  with 

uterus. 
No  decidual  membrane  cast  off. 
Absence  of  attacks  of  very  severe 

sharp  pain,  with  symptoms  of 

collapse. 


Extra-uterine  Gestation. 

Menstrual     period    or     period* 

usually  skipped. 
Grows  more  rapidly. 
More  lateral. 
Less  intimately  connected  with 

uterus. 
Decidual  membrane  cast  off. 
Such  attacks  occur. 


How  would  you  differentiate  a  fibroid  tumor  from  a  pelvic 
haematocele  ? 


Fibroid  Tumor 
Gradual  development. 
Absence  of  acute  symptoms. 

Insensitive  to  pressure. 
Hard  and  firm. 
Moves  with  uterus. 


vs.  Pelvic  Hcematocele. 

Rapid  development. 
Symptoms  of  sudden  sharp  pain, 

shock  and  hemorrhage. 
Sensitive  to  pressure. 
First  soft,  later  harder. 
Does  not  move  with  uterus, 


158  ESSENTIALS   OF   GYNAECOLOGY. 

How  would  you  differentiate  a  fibroid  tumor  from  a  pelvic 
inflammatory  deposit? 

Fibroid  Tumor  vs.  Inflammatory  Deposit. 

Slow  growth  ;  no  history  of  acute      History  of  rapid   development, 

inflammation.  and  acute  inflammation. 

Moves  with  uterus,  and  seems  a      Usually    does    not    move    with 
part  of  it.  uterus,  and  seems  less  a  part 

of  it. 
Insensitive  to  pressure.  Sensitive  to  pressure. 

What  is  the  treatment  ? 

Palliative. — The  administration  of  ergot  in  some  cases  will  keep 
the  symptoms  under  control  until  after  the  menopause,  when  the 
symptoms,  as  a  rule,  gradually  disappear  ;  the  menopause,  however, 
is  usually  considerably  delayed. 

If  endometritis  is  associated  with  the  fibroid,  curetting  the  uterus 
is  often  of  value. 

Curative. — Tait's  operation  of  removal  of  the  ovaries  and  tubes, 
artificially  producing  the  menopause,  is  perhaps  the  best  general  plan 
o\  treatment.     In  some  cases  hysterectomy  is  indicated. 

Apostoli's  treatment  by  means  of  galvanism  with  currents  of  high 
intensity  is  still  subjudice. 

When  the  tumor  is  subperitoneal  and  pedunculated,  myomotomy 
may  be  indicated. 

Inversion  of  the  Uterus. 

What  is  the  pathology? 

In  inversion,  the  uterus  is  turned  more  or  less  completely  inside  out 
(see  Fig.  47). 

It  may  be  either — 

1.  Partial — where  the  depressed  uterine  wall  does  not  extend 
beyond  the  os  externum  ;  or 

2.  Complete — where  the  inverted  body,  covered  with  mucous 
membrane,  lies  outside  of  the  os  externum,  either  in  the  vagina  or 
between  the  labia. 

The  mechanism  of  production  of  the  inversion  is  as  follows  :— 
A  portion  of  the  uterine  wall  loses  its  tone,  is  depressed  into  the 


INVERSION    OF  THE   UTERUS. 


159 


uterine  cavity,  usually  by  traction  from  below  or  abdominal  pressure 
from  above ;  the  depressed  portion  is  then  grasped  by  the  unde- 
pressed portion  and  forced  toward  or  through  the  cervix. 

The  peritoneum  follows  the  depression  of  the  uterine  wall,  and 
lines  the  cup  thus  formed.  The  appendages  may  or  may  not  lie 
within  the  cup. 

The  inversion  occurring  during  the  puerperium  usually  begins  at 
the  placental  site  ;  when  produced  by  intra-uterine  tumors,  it  usually 
begins  at  the  attachment  of  the  tumor.  The  uterine  mucous  mem- 
brane is  usually  congested  ;  it  may  ulcerate  ;  sometimes  it  becomes 
gangrenous.  Occasionally  it  becomes  covered  with  squamous  epi- 
thelium, and  resembles  skin. 

Fig.  47. 


Inversion  of  Uterus  (half-size,  Barnes  from  Crosse's  essay).  The  fundus  lies  in  the 
vagina;  the  cervix  is  not  inverted;  the  lips  are  flattened  out  to  a  swelling  seen 
below  the  angle  of  inversion.  The  ovaries  (seen  from  behind)  are  not  in  the 
peritoneal  cup. 

What  is  the  etiology  ? 

Inversion  is  predisposed  to  by — 

(a.)  Parturition. 

(b. )  Distention  of  the  uterus  from  any  cause. 

( c. )  Intra-uterine  tumors. 

(d. )  Degeneration  of  uterine  walls. 
According  to  the  time  and  cause  of  production,  two  varieties  are 
recognized  : — 

1.  Puerperal. — Produced  during  the  puerperium,  either  by  ab- 


160  ESSENTIALS   OF  GYNAECOLOGY. 

doniinal  pressure  or  mismanagement  in  the  delivery  of  the  placenta, 
especially  the  latter,  traction  on  the  cord  being  the  most  frequent 
cause. 

2.  Non-puerperal. — Secondary  to  intra-uterine  tumors  ;  especially 
pedunculated  fibroids  growing  from  the  fundus. 

The  puerperal  variety  is  much  more  common  than  the  non-puer- 
peral. The  former  is  usually  rapid  in  development ;  the  latter 
gradual. 

When  the  inversion  is  developed  and  reduced  during  the  puer- 
perium,  it  is  called  acute  ;  otherwise,  chronic  inversion. 

What  are  the  symptoms  ? 

At  the  time  of  the  occurrence  of  acute  inversion,  there  is  pain, 
hemorrhage,  shock,  a  feeling  as  of  something  giving  way,  and  of  full- 
ness in  the  vagina. 

This  belongs  especially  to  obstetrics. 

The  symptoms  of  the  chronic  inversion  are  hemorrhage,  dragging 
pain  in  the  pelvis,  discomfort  from  the  foreign  body  in  the  vagina, 
leucorrhcea,  anaemia  and  general  malaise.  Rarely  inversion  exists 
with  very  few  symptoms. 

What  are  the  physical  signs  ? 

These  depend  on  whether  the  inversion  is  partial  or  complete,  acute 
or  chronic.  In  the  partial  variety  the  cupping  may  be  felt  by  the 
hand  on  the  abdomen,  and  the  inverted  portion  detected  by  the  use 
of  the  sound  in  the  uterus.  In  the  acute,  complete  inversion,  one 
feels  a  soft,  bulging  tumor  in  the  vagina  or  between  the  labia  ;  it 
bleeds  easily,  is  sensitive  and  smaller  above  where  it  is  encircled  by 
the  cervix  ;  it  may  or  may  not  have  the  placenta  attached  to  it.  The 
sound  passes  around  the  tumor,  but  only  a  short  distance  into  the 
cervix.  The  hand  on  the  abdomen  detects  the  absence  of  the  fundus 
and  the  presence  of  the  cervical  ring.  The  physical  signs  of  the 
chronic  inversion  are  similar,  save  that  the  mass  in  the  vagina  is 
smaller,  harder,  and  in  the  non-puerperal  variety  perhaps  has 
attached  to  it  the  tumor  which  was  its  cause. 

From  what  must  you  differentiate  inversion  of  the  uterus  ? 
From  polypi  and  prolapsus  uteri. 


INVERSION   OF  THE  UTERUS. 


161 


How  would  you  differentiate  inversion  of  the  uterus  from  a 
polypus  ? 

The  diagnosis  of  a  complete  inversion  (see  Fig.  48)  from  a  polypus 
lying  in  the  vagina  (see  Fig.  49)  would  be  made  as  follows : — 


Inversion 
Fundus  not  felt  in  the  abdomen ; 

cervical  ring  felt. 
Sound  passes  all  around  tumor, 

but  only  a  short  distance  into 

the  cervix. 


vs.  Polypus. 

Fundus  felt  in  the  abdomen. 

Sound  passes  into  the  uterus,  at 
the  side  of  the  tumor,  more 
than  2  ^  inches. 


Fig.  49. 


Fig.  48. 


Inversion  of  Uterus  (after 
Thomas).  A  cup-shaped 
depression  is  in  the  place 
of  the  uterus.  Sound  ar- 
rested at  angle  of  flexion. 


Uterine  Polypus  (after 
Thomas).  The  uterus 
in  its  normal  position. 
Sound  passes  into 
uterine  cavity. 


The  differential  diagnosis  between  a  partial  inversion  and  an  intra- 
uterine polypus  (see  Figs.  50  and  51)  is  often  quite  difficult.     Careful 
examination  by  the  ordinary  bimanual  and  by  the  abdomino-rectal 
method  may  detect  the  cup-shaped  depression  of  the  partial  inver- 
11 


162 


ESSENTIALS   OF  GYNAECOLOGY. 


sion.     Enlargement  of  the  uterus  rather  favors  the  diagnosis  of 
polypus. 
Both  of  these  conditions  may  rarely  coexist. 

How  would  you  differentiate  inversion  of  the  uterus  from 
complete  prolapse  ? 

This  rarely  causes  difficulty.  It  is  made  by  finding  in  the  latter 
the  external  os,  the  obliteration  of  the  fornices,  and  by  passing  the 
sound  into  the  uterine  canal. 

What  are  the  results  of  an  untreated  inversion  ? 

Very  rarely  it  reduces  itself.  Rarely  the  patient  suffers  little 
inconvenience  from  it. 

Usually  the  patient  dies  from  hemorrhage  or  sepsis. 

Fig.  51. 
Fig.  50. 


Partial  Inversion  of  Uterus 
(after  Thomas). 


Polypus  still  Intra-uterine 
(after  Thomas). 


What  is  the  treatment  ? 

The  object  sought  is  the  reposition  of  the  fundus  uteri. 

Emmet's  method  (sec  Fig.  52)  consists  in  inserting  the  right  band 
into  the  vagina,  grasping  the  fundus  in  the  palm,  inserting  the 
fingers  into  the  cervix  and  pushing  upward  ;  at  the  same  time  sepa- 
rating the  fingers  as  mucb  as  possible.  The  left  hand  meanwhile 
exercises  through  the  abdomen  counter-pressure  on  the  cervical  ring. 

Noeggerath  begins  the  reposition  by  dimpling  in  one  horn  of  the 
uterus,  and  then  uses  this  as  a  wedge  to  dilate  the  cervix. 


POLYPI. 


163 


Instead  of  the  hand  alone,  cup-shaped  repositors  are  often  made 
use  of. 

In  all  these  methods  the  patient  is  usually  best  prepared  for  the 
manipulation  by  the  administration  of  prolonged  hot-water  douches, 
and  the  introduction  of  a  vaginal  elastic  bag,  to  be  distended  with 
air  or  water,  and  worn  twelve  to  twenty-four  hours. 

The  manipulations  are  best  performed  under  anaesthesia. 

When  the  above  methods  fail,  hysterectomy  probably  offers  the 

best  result. 

Fig.  52. 


Reposition  of  the  Inverted  Uterus  with  the  Hand  alone  (after  Emmet). 


Polypi. 

What  is  meant  by  the  term  " uterine  polypus,"  and  what 
are  the  varieties? 

A  polypus  is  a  pedunculated  tumor  attached  to  the  uterine  mucous 
membrane.     The  following  varieties  are  recognized  : — 

1.  Fibrous  polypi. 

2.  Mucous  polypi. 

3.  Pedunculated  Nabothian  follicles. 

4.  Placental  polypi. 

5.  Papillomata  of  the  cervix, 


164 


ESSENTIALS   OF   GYNAECOLOGY. 


Describe  briefly  the  fibrous  polypi. 

Fibrous  polypi  are  submucous  fibroids  which  have  become  pedun- 
culated ;  at  first  lying  within  the  uterus ;  later,  dilating  the  cervix 
and  becoming  vaginal  (see  Fig.  53),  sometimes  even  projecting 
beyond  the  vulva. 

They  spring  from  the  muscular  wall  of  the  uterus,  more  often 

Fig.  53. 


Intra-uterine  Submucous  Fibroid  which  is  becoming  Vaginal  (Sir  J.  T.  Simpson). 

from  the  body  than  cervix;  they  are  composed  chiefly  of  fibrous 
tissue  with  few  blood  vessels.  Their  presence  sets  up  uterine  con- 
tractions, which  gradually  expel  them.  Their  shape  is  usually 
pyriform  or  ovoid. 

Describe  the  mucous  polypi. 

These  spring  from  the  uterine  mucous  membrane,  chiefly  that  of 
the  cervix.     There  are  usually  more  than  one  (see  Fig.  54)  ;  they  arc 


POLYPI. 


165 


small,  soft,  vascular,  and  on  section  present  the  structure  of  mucous 
membrane. 

What  are  the  pedunculated  Nabothian  follicles  ? 

They  are  the  glands  of  the  cervical  mucous  membrane  which  have 
become  obstructed,  formed  retention  cysts  and  assumed  the  polypoid 
.shape. 

What  are  placental  polypi  ? 

They  are  portions  of  undetached  placenta  which  have  received  nutri- 

Fig.  54. 


Group  of  Mucous  Polypi  growing  in  the  Cervix  Uteri  (Sir  J.  Y.  Simpson). 

ment  from  their  attachment  to  the  uterus,  have  become  coated  with 
fibrin  and  so  increased  in  size.  By  the  uterine  contractions  they  are 
made  more  pedunculated,  and  may  be  extruded  from  the  cervix. 

Describe  the  papillomatous  variety  of  polypus. 

Papilloma  of  the  cervix  is  almost  always  either  a  malignant  new 
growth  or  tends  soon  to  become  so.  It  is  often  called  a  "cauli- 
flower excrescence ' '  (Clarke),  (see  Fig.  55),  is  usually  soft,  friable. 
and  bleeds  easily. 


166 


ESSENTIALS   OF  GYNAECOLOGY. 


What  are  the  symptoms  of  polypi  ? 

1.  Hemorrhage. — First    menorrhagia,    then    metrorrhagia,   the 

source  of  the  blood  being  the  mucous  membrane,  which  covers,  or 
in  the  mucous  variety  forms,  the  substance  of  the  polypus. 

2.  Leucorrlicea. — Due  to  the  accompanying  endometritis. 

3.  Pain. — Due  to  the  efforts  of  the  uterus  to  expel  the  tumor. 

4.  Sterility. — Due  to  the  mechanical  obstruction  and  to  the  endo 

metritis. 
Fig.  55.  5.  Anaemia  and  general  malaise. — 

Resulting  from    the    foregoing  condi- 
tions. 

What  are  the  physical  signs  ? 

When  the  polypus  has  passed  the  OS' 
externum,  the  finger  in  the  vagina  de- 
tects a  pyriform  or  ovoid  body,  hard  or 
soft  according  to  the  variety ;  it  is 
movable  and  seems  to  come  from  the 
os.  The  use  of  the  speculum  deter- 
mines its  appearance. 

If  it  is  a  fibrous  polypus,  the  bi- 
manual examination  usually  shows  the 
uterus  enlarged,  and  the  sound  proves 
the  cavity  elongated. 

When  the  polypus  is  intra-uterine, 
the  sound  in  some  cases  will  detect  its 
presence ;  in  other  cases  dilatation  of 
the  cervix  and  introduction  of  the  fin- 
ger is  necessary. 

The    fibrous   polypus,   according-  to> 
Hart  and  Barbour,  is  larger  than  a  wal- 
nut and  of  firm  consistency. 
The  mucous  polypus  is  about  the  size  of  an  almond  and  of  a  pulpy 
consistency. 

For  differential  diagnosis  between  inversion  of  the  uterus  and 
polypi  see  inversion. 

What  is  the  treatment  ? 
When  the  polypus  is  of  considerable   size   and  lies  within  or 


Cauliflower  Excrescence  growing 
from  the  Cervix  Uteri  (Sir  J. 
Y.  Simpson). 


CARCINOMA  UTERI.  167 

external  to  the  os,  the  best  treatment  is  removal  by  the  wire 
ecraseur,  putting  the  wire  loop  as  near  the  uterine  attachment  of 
the  pedicle  as  possible. 

Small  polypoid  projections  may  be  scraped  away  with  the  curette  ; 
mucous  polypi  may  usually  be  twisted  off  with  the  forceps. 
;     When  the  polypus  lies  within  the  uterus,  dilate  the  cervix  with 
Allen's  pump  or  a  tupelo  tent  and  apply  the  ecraseur. 

If  the  pedicle  is  small,  blunt,  dull  scissors  may  be  substituted  for 
the  ecraseur.  If  the  pedicle  is  large  or  dilatation  of  the  cervix  is 
necessary,  anaesthesia  is  to  be  employed. 

All  antiseptic  precautions  are  to  be  used. 


Carcinoma  Uteri. 

What  is  the  pathology  ? 

Carcinoma,  with  its  usual  microscopical  characteristics,  may  involve 
either  the  body  of  the  uterus  or  the  cervix  ;  it  is  very  much  more 
frequent  in  the  latter,  and  the  usual  form  is  epithelioma.  It  may 
begin  on  the  vaginal  portion  of  the  cervix,  in  the  substance  of  the 
cervix,  or  in  the  mucous  membrane  of  the  canal. 

When  situated  on  the  vaginal  portion  it  often  begins  as  an  indu- 
ration of  the  superficial  layers,  which  then  ulcerate  with  irregular 
and  indurated  edges.  It  may  take  the  form  of  cauliflower  excres- 
cences. 

When  beginning  as  nodules  in  the  substance  of  the  cervix,  these 
nodules  enlarge,  come  to  the  surface  of  the  mucous  membrane  and 
ulceration  follows. 

When  beginning  in  the  mucous  membrane  of  the  canal,  it  may 
excavate  the  whole  canal  and  extend  to  the  parametrium. 

Carcinoma  of  the  body  of  the  uterus  usually  begins  in  the  endo- 
metrium. Whether  it  ever  begins  in  the  substance  of  the  uterine 
wall  is  a  disputed  point.  It  may  be  circumscribed  or  diffuse.  It 
often  assumes  a  polypoid  shape. 

What  is  the  etiology  ? 

The  etiology  of  cancer  of  the  uterus  is  still  unsettled.  The  factors 
which  favor  its  development  are  age,  heredity,  parturition,  laceration 
of  the  cervix,  with  erosion  and  depreciation  of  the  vital  powers. 


168  ESSENTIALS  OF  GYNAECOLOGY. 

1.  Age. — It  occurs  most  frequently  between  the  ages  of  40-50. 

2.  Heredity. — Although  regarded  as  of  less  importance  than  for- 
merly, its  influence  seems  to  be  exemplified  in  some  cases. 

3.  Pirtnrition. — Frequent  child-bearing  apparently  creates  a 
marked  predisposition. 

4.  Laceration  of  the  Cervix. — Cancer  of  the  cervix  seems  often  to 
arise  from  a  laceration,  with  erosion  and  cervical  endometritis. 

5.  Depreciation  of  the  Vital  Powers. — Poor  surroundings,  poor 
food  and  air  and  hardships  of  any  kind  seem  to  predispose  to  cancer. 

What  are  the  symptoms  ? 

1.  Hemorrhage. — This  is  usually  the  first  symptom.  If  hemor- 
rhage occurs  after  the  menopause,  always  suspect  cancer. 

2.  Offensive  Discharge. — Does  not  occur  until  ulceration  begins. 

3.  Pain. — When  the  cervix  is  alone  involved,  pain  is  usually  ab- 
sent. When  the  disease  has  extended  to  the  cellular  tissue  or  peri- 
toneum, or  involves  the  body,  pain  is  common. 

4.  Cachexia. — This  is  always  present  to  a  greater  or  less  extent 
in  the  later  stages. 

What  are  the  physical  signs? 

If  the  disease  affects  the  vaginal  portion  of  the  cervix,  the  exam- 
ining finger  detects  a  rough,  ulcerated  and  indurated  area,  or  perhaps 
a  fungoid  mass.  On  withdrawal,  the  finger  is  usually  stained  with 
blood  and  emits  a  foul  odor.  The  speculum  gives  us  the  appearance 
of  the  growth. 

When  the  uterine  canal  is  involved,  the  sound  usually  detects  the 
abnormal  condition,  which  may  be  diagnosed  by  microscopical  exam- 
ination of  fragments  removed  by  curetting.  In  cancer  of  the  body, 
the  uterus  is  usually  enlarged. 

What  is  the  treatment  of  carcinoma  of  the  uterus  ? 
1.   Radical. — 

(a)  Vaginal  hysterectomy. 
{!>)  High  amputation  of  the  cervix. 
When  the  disease  is  confined  to  the  body  of  the  uterus  and  the 
latter  is  movable,  hysterectomy  is  indicated. 

When  the  disease  involves  the  cervix,  and  operation  is  not  con- 
tra-indicated by  extension  of  the  disease  to  the  parametria  or  vagi- 


CARCINOMA  UTERI.  169 

rial  walls,  either  hysterectomy  or  high  amputation  of  the  cervix  may 
be  performed.  Authorities  differ  in  their  choice  of  the  two  opera- 
tions, the  preference  at  the  present  time  being  most  often  given  to 
hysterectomy. 

2.  Palliative. — When  a  radical  operation  is  contraindicated,  the 
following  methods  of  treatment  are  of  value  : — 

If  hemorrhage  is  a  marked  symptom,  and  sloughing  masses  are 
present  at  the  seat  of  ulceration,  thoroughly  curette  the  surface  and 
apply  carbolic  acid,  iodized  phenol,  or  a  solution  of  chloride  of  zinc. 
Frequent  insertions  of  iodoform  gauze  soaked  in  a  4  per  cent,  solu- 
tion of  chloral  will  be  found  to  act  as  an  antiseptic  and  anaesthetic  to 
the  ulcerated  surface. 

For  the  foul  discharges,  vaginal  douches  of  a  weak  solution  of  creo- 
lin  are  valuable. 

The  pain  and  distress  in  the  later  stages  demand  opium. 

Attention  to  the  general  health  is  of  course  indicated. 

Describe  briefly  the  operation  of  vaginal  hysterectomy. 

Different  operators  differ  somewhat  in  the  details  of  the  operation. 
The  main  features  of  the  operation  are  as  follows:  The  vulva  is 
shaved,  and  the  vagina  and  vulva  thoroughly  disinfected.  The 
uterus  is  drawn  down  and  held  by  an  assistant;  a  semicircular 
incision  is  made  around  the  cervix  in  the  anterior  fornix,  and  the 
cervix  is  separated  from  the  bladder  up  to  the  utero-vesica] 
pouch  of  the  peritoneum.  The  cervix  is  drawn  forward  and  the 
posterior  fornix  opened  by  a  semicircular  incision  about  the  cervix, 
which  is  then  freed  up  to  the  pouch  of  Douglas.  The  pouch  of 
Douglas  may  now  be  opened,  and  a  clean  sponge,  with  a  silver  wire 
attached,  introduced  to  keep  back  the  intestines.  The  uterus  is 
freed  from  the  lower  portion  of  the  broad  ligaments  by  clamping  or 
ligaturing  in  section,  and  then  cutting  with  scissors  close  to  the 
uterus.  The  latter  may  now  be  retroverted  through  the  opening  in 
the  pouch  of  Douglas,  and  freed  from  the  upper  portion  of  the 
broad  ligaments  by  clamping  or  ligaturing,  and  cutting  close  to  the 
uterus.  It  is  well  to  draw  the  ovaries  into  the  clamp  or  ligature,  so 
that  they  will  be  removed  with  the  uterus.  The  anterior  reflection 
of  peritoneum  may  now  be  divided,  or,  as  practiced  by  many  opera- 
tors, this  may  be  done  before  retroverting  the  uterus.     All  hemor- 


170 


ESSENTIALS  OF  GYNECOLOGY. 


rhage  is  checked  and  the  parts  irrigated :  the  peritoneum  is  some- 
times stitched  to  the  vaginal  wall,  but  this  is  unnecessary.  The 
parts  are  dusted  with  iodoform,  and  an  iodoform  gauze  vaginal 
dressing  applied.  If  the  broad  ligaments  have  been  clamped,  the 
clamps  should  be  left  on  about  forty-eight  hours. 

Describe  the  operation  for  high  amputation  of  the  cervix. 

The  cervix  is  drawn  down  with  a  volsella  and  held  by  an  assistant ; 
an  incision  is  made  through  the  anterior  fornix  around  the  cer- 
vix, and  the  latter  is  separated  from  the  bladder  nearly  to  the 

Fig.  56. 


Line  of  Incision  and  Position  of  Sutures  in  the  Supra-vaginal  Amputation 
of  the  Cervix  (Schroeder). 


peritoneum.  The  cervix  is  now  drawn  forward,  the  posterior  fornix 
opened,  and  the  cervix  freed  behind  as  in  front.  The  knife  is 
carried  through  the  anterior  lip  to  the  cervical  canal  at  the  desired 
height  (see  Fig.  56).  The  posterior  lip  is  then  amputated  in  a  similar 
manner.  The  anterior  lip  and  anterior  vaginal  wall  are  united 
by  sutures;  also  the  posterior  lip  and  post-vaginal  wall  (see  Fig.  5G). 
It  is  usually  necessary  to  suture  the  ends  of  the  wound  in  the  lateral 
fornices. 


SARCOMA  OF  THE  UTERUS.  3  71 

Sarcoma  of  the  Uterus. 

What  is  the  pathology  ? 

Sarcoma,  a  new  growth  developing  from  the  connective  tissue  and 
presenting  the  microscopical  characteristics  of  sarcoma  elsewhere, 
occurs  in  the  uterus,  either  in  the  form  of  a  diffuse  infiltration  or  as 
■a  circumscribed  tumor.  It  usually  affects  the  body  of  the  uterus, 
being  rare  in  the  cervix.  The  masses  are  usually  grayish  in  color, 
soft  and  brain-like ;  occasionally  the  circumscribed  masses  are  firm 
and  resemble  fibroids,  but  have  no  capsule.  They  usually  do  not 
ulcerate  as  rapidly  or  deeply  as  carcinoma,  and  metastases  are  less 
common. 

What  is  the  etiology  ? 

Little  is  known  concerning  it.  It  is  most  frequent  between  the 
ages  forty  to  fifty,  but,  unlike  carcinoma,  often  occurs  in  nulliparous 
women. 

What  are  the  symptoms  ? 

1.  Hemorrhage. 

2.  Watery  discharge. 

3.  Pain. 

4.  Cachexia. 

Thus  the  symptoms  are  similar  to  those  of  carcinoma.  Some 
authors  claim,  however,  that  the  discharge  is  less  offensive  than  in 
carcinoma,  because  there  is  less  tissue  necrosis. 

What  are  the  physical  signs  ? 

The  uterus  is  usually  enlarged;  the  sound,  when  introduced, 
detects  great  irregularity  of  the  endometrium,  and  usually  causes 
bleeding.  If  the  curette  is  used,  a  grayish,  brain-like  material  is 
removed. 

With  what  are  sarcoma  and  carcinoma  of  the  body  of  the 
uterus  most  likely  to  be  confused,  and  how  is  the 
diagnosis  made? 

They  are  chiefly  to  be  confused  with  villous  endometritis,  sloughing 
polypi  or  retained  secundines.  The  diagnosis  is  made  by  removing 
fragments  with  the  curette,  knife  or  scissors,  and  subjecting  them  to 


172  ESSENTIALS  OF  GYNAECOLOGY. 

microscopical  examination.  Marked  anaemia  and  emaciation  would 
lead  one  to  suspect  malignant  disease,  yet  severe  endometritis  or  a 
vascular  polypus  may  cause  similar  symptoms. 

What  is  the  treatment  ? 

Hysterectomy  gives  us  the  only  prospect  of  cure. 

The  palliative  treatment  consists  in  curetting  and  applying  caustiss 
to  the  interior  of  the  uterus,  keeping  the  vagina  clean  with  anti- 
septic douches,  as  weak  creolin,  and  relieving  pain  with  opium. 


Salpingitis. 

What  is  the  pathology  ? 

In  salpingitis  there  is  usually  first  a  catarrhal  inflammation  of  the 
mucous  membrane  of  the  tube ;  this  extending  to  the  peritoneum 
sets  up  a  localized  peritonitis  which  usually  closes  the  fimbriated  ex- 
tremity, and  often  by  adhesions  distorts  the  tube.  From  the  closui  t 
of  the  outer  extremity  and  the  narrowing  of  the  lumen  in  dif- 
ferent places  by  the  traction  of  peritonitic  adhesions,  the  secretions 
are  retained  and  distend  the  tube.  This  distention  is  favored  by 
the  softening  arising  from  the  catarrhal  inflammation.  Other  por- 
tions of  the  tube  may  be  thickened,  partly  from  inflammation  of 
the  tube  itself  and  partly  from  the  neighboring  peritonitis.  In 
some  cases  the  obstruction  at  the  uterine  end  of  the  tube  is  over- 
come by  the  pressure  of  the  tubal  contents,  which  may  then  be 
expelled  into  the  uterus  and  vagina,  constituting  the  condition  called 
"salpingitis  profluens." 

The  varieties  of  salpingitis,  named  according  to  the  tubal  content  3 
are — 

1.  Hydrosalpinx. 

2.  Hematosalpinx. 

3.  Pyosalpinx. 

Tubercular  salpingitis  is  now  thought  to  occur  either  as  a  primary 
or  secondary  affection. 

What  is  the  etiology  of  salpingitis  ? 

It  usually  arises  from  an  extension  to  the  tube  of  an  inflammation 


SALPINGITIS.  173 

of  the  endometrium,  and  its  etiology  is  that  of  the  endometritis, 

especially — 

1.  Sepsis  during  parturition  or  abortion. 

2.  The  use  of  septic  instruments. 

3.  Gonorrhoea. 

What  are  the  characteristics  of  a  hydrosalpinx  ? 

In  a  hydrosalpinx  the  tube  is  distended  with  serum,  the  result  of 
a  catarrhal  inflammation.  The  softening  of  the  walls  easily  allows 
the  distention,  which  varies  in  position  according  to  the  traction  of 
peritonitic  adhesions. 

What  are  the  characteristics  of  a  hematosalpinx  ? 

Here  the  tube  is  distended  with  blood,  which  may  have  one  of 
three  sources  \— 

1.  It  may  be  exuded  from  the  tubal  mucous  membrane  as  a  result 
of  the  catarrhal  inflammation. 

2.  It  may  occur  as  an  extension  of  a  hseniatornetra  due  to  atresia 
of  vagina  or  cervix. 

3.  It  may  occur  as  a  result  of  a  tubal  pregnancy. 

The  tube  is  usually  first  hypertrophied,  later  thinned,  and  it  may 
rupture  ;  this  accident  is  usually  delayed  by  peritonitic  thickening 
about  the  tube.     The  blood  is  generally  thick  and  tarry. 

What  are  the  characteristics  of  a  pyosalpinx  ? 

The  tube  is  usually  more  thickened  and  surrounded  by  more  peri- 
tonitic adhesions  than  is  hydrosalpinx. 

The  pus  may  be  slight  in  amount,  or  the  tube  may  be  immensely 
distended  with  very  fetid  pus. 

Adhesions  are  apt  to  form  between  tube  and  neighboring  viscera, 
and  the  pus  sometimes  ruptures  into  them,  especially  into  rectum  or 
bladder. 

What  are  the  symptoms  of  salpingitis  ? 

The  patient  usually  suffers  from  a  burning  and  dragging  pain  in 
the  region  of  the  affected  tube,  especially  on  standing  and  walking. 
Dysmenorrhoea  is  common  ;  repeated  attacks  of  peritonitis  are  not 
infrequent.  In  the  case  of  pyosalpinx  septic  symptoms  may  be  pres- 
ent.    There  is  tenderness  on  pressure  in  the  lateral  vaginal  fornix, 


174  ESSENTIALS  OF  GYNAECOLOGY. 

and  on  making  a  bimanual  examination  an  elongated  cystic  mass  can 
usually  be  detected  at  the  side  of  the  uterus. 

What  are  the  results  of  salpingitis  ? 

A  hydrosalpinx  or  hematosalpinx  occasionally  subsides  so  as  to 
cause  few  symptoms ;  they  may  become  purulent  and  form  pyo- 
salpinx. 

A  hematosalpinx  may  rupture  into  the  peritoneum  or  into  the 
broad  ligament,  forming  an  hematocele  in  the  former  case,  and  a 
hematoma  in  the  latter. 

A  pyosalpinx  if  unrelieved  by  operation  may  continue  for  years, 
producing  chronic  invalidism,  or  may  rupture  and  cause  septicemia 
or  peritonitis. 

What  is  the  treatment  of  salpingitis  ? 

1 .  Prophylactic.  — Cleanliness  and  antisepsis  during  the  puerperium 
and  in  the  use  of  all  instruments. 

2.  Palliative. — During  the  acute  stage  of  invasion,  rest  in  bed, 
poultices,  and,  if  much  pain  is  present,  allow  opium. 

When  the  case  becomes  subacute,  apply  counter  irritation  to  vaginal 
fornix  over  the  aifected  tube  or  tubes,  and  employ  tampons  of  boric 
acid  and  glycerine  and  hot  water  vaginal  douches. 

3.  Radical. — If  the  distention  and  thickening  of  the  tube  fails  to 
subside  under  the  foregoing  treatment,  perform  laparotomy  and 
remove  the  tube  and  ovary  of  the  side  affected.  Usually  both  sides 
are  involved  and  require  removal. 

In  a  pyosalpinx,  if  complete  removal  is  impossible  or  it  has  rup- 
tured into  the  broad  ligament,  it  may  be  best  to  drain  through  the 
vagina. 

Affections  of  the  Ovaries. 
Hemorrhage  into  the  Ovaries. 

What  is  the  etiology  and  pathology  ? 

Hemorrhage  into  the  ovary  is  caused  by  anything  producing  a  con- 
gestion of  the  organ,  such  as  obstruction  to  the  circulation,  pelvic 
diseases,  tumors,  disorganization  of  the  blood,  disease  of  heart  or 
lungs,  catching  cold  during  menstruation,  and  excessive  or  violent 
sexual  intercourse.     The  heinonlnige  maybe  either  follicular,  occur 


AFFECTIONS  OF  THE  OVARIES.  175 

ring  into  the  Graafian  follicles,  or  interstitial.  The  former  being  com- 
paratively frequent,  the  latter  rare.  The  ovary  is  usually  enlarged 
and  irregular  in  shape  and  more  sensitive  to  pressure  ;  the  follicles 
may  rapture  and  form  pelvic  hematocele  or  set  up  peritonitis. 

What  are  the  symptoms  ? 

Although  the  hypersemia  of  the  ovary  may  be  suspected  from 
monorrhagia,  throbbing  pains  over  the  ovaries  and  their  acute 
enlargement,  no  positive  symptoms  are  produced  until  rapture 
occurs,  when,  according  to  the  amount  of  blood  poured  out,  they 
may  vaiy  from  symptoms  of  slight  pain  and  shock  to  those  of  fatal 
hemorrhage  and  collapse. 

"What  is  the  treatment  ? 

While  hyperEeruia  of  the  ovary  is  suspected,  regulate  the  mode  of 
life  and  enjoin  rest  just  before  and  during  the  early  part  of  menstru- 
ation. Apply  counter-irritation  to  the  ovarian  region ;  attempt  to 
elevate  the  ovaries  by  soft  packing  if  they  are  prolapsed,  and 
administer  hot-water  vaginal  douches.  If  rapture  occurs,  the  treat- 
ment is  that  of  pelvic  peritonitis  or  haematocele. 

Ovaritis. 
What  is  the  pathology  ? 

Ovaritis  or  inflammation  of  the  ovary  may  be  acute  or  chronic. 

Tubercular  ovaritis  is  usually  described  separately. 

Acute  ovaritis  may  be  follicular  or  interstitial ;  the  two  are  often 
combined.  In  the  follicular  form,  the  epithelium  of  the  follicles 
degenerates,  the  liquor  folliculi  becomes  purulent,  and  the  ovum  is 
destroyed. 

In  the  interstitial  form,  the  stroma  is  infiltrated  with  seram  and 
leucocytes  and  the  connective  tissue  cells  are  increased  ;  abscesses 
often  form  between  the  bundles  of  fibers ;  sometimes  gangrene 
occurs. 

Chronic  ovaritis,  often  the  result  of  the  acute,  may  exhibit  3 
forms — 

1.  The  atrophic. 

2.  The  hyperplastic. 

3.  The  cystic. 


176  ESSENTIALS  OF  GYNAECOLOGY. 

In  the  atrophic  form  the  ovary  is  small,  hard,  and  nodular ;  the 
tunica  albuginea  is  much  thickened. 

In  the  hyperplastic  form,  the  ovary  is  enlarged,  hard,  and  com- 
paratively smooth  ;  it  usually  prolapses  from  the  increased  weight. 

In  the  cystic  variety,  the  change  is  not  confined  to  the  follicles,  but 
the  stroma  is  involved  as  well. 

The  atrophic  form  may  be  present  in  one  part  of  the  ovary  and  the 
hyperplastic  in  another ;  the  tunica  albuginea  is  thickened  and 
prevents  rupture  of  the  cysts.  Ovaries  the  seat  of  ovaritis  are 
usually  more  or  less  surrounded  by  peritonitis. 

What  is  the  etiology  of  ovaritis  ? 

It  occasionally  occurs  in  severe  cases  of  the  infectious  diseases  or 
metallic  poisoning,  but  is  most  often  secondary  to  disease  of  the 
tubes  or  peritoneum.  It  is  predisposed  to  by  anything  causing  con- 
gestion of  the  ovary,  such  as  displacement  of  the  uterus  or  ovary  or 
excessive  venery.  A  salpingitis  with  its  own  etiology  is  the  most 
frequent  cause  of  ovaritis.  Among  individual  causes,  the  following 
are  especially  to  be  mentioned  : — 

Sepsis  during  labor,  abortion  or  operations. 

Gonorrhoea. 

Catching  cold  during  menstruation. 

What  are  the  symptoms  ? 

The  symptoms  of  acute  ovaritis  are  usually  mingled  with  those 
of  the  accompanying  salpingitis  or  peritocitis.  There  is  generally 
sharp  pain  in  the  ovarian  region  or  regions,  radiating  to  the  back; 
often  pain  in  micturition  and  defecation,  and  various  reflex  neuroses. 
If  an  abscess  forms,  septic  symptoms  may  be  present. 

In  the  chronic  form  the  symptoms  are  usually  less  marked  ;  there 
is  dull  pain  in  the  ovarian  region,  increased  by  walking.  There  is 
dyspareunia  and,  especially  if  the  ovary  is  prolapsed,  painful  defe- 
cation. 

What  are  the  physical  signs  ? 

These  may  Ik;  obscure,  from  the  fact  that  the  ovary  and  tube  are 
bound  together  by  peritonitic  adhesions  into  one  indistinct  mass. 

When  definable,  we  led,  on  making  a  bimanual  examination,  a 
round  body  at  the  side  of  the  uterus,  but  separated   from   it-  by  a 


AFFECTIONS   OF  THE  OVARIES.  177 

slight  interval ;  it  is  sensitive  to  pressure,  producing  pain  of  a  sick- 
ening character ;  it  may  or  may  not  be  movable.  When  the  ovary 
is  prolapsed,  this  round,  tender  mass  may  be  felt  in  the  pouch  of 
Douglas. 

From  what  must  you  differentiate  an  inflamed  ovary  ? 

From —  Salpingitis. 

Peritonitic  deposit. 

Exudation  into  the  broad  ligament. 

Fibroid  tumor. 

Faeces  in  the  rectum. 

How  would  you  differentiate  ovaritis  from  salpingitis  ? 

This  is  often  very  difficult,  from  the  fact  that  the  two  conditions 
frequently  coexist.  The  chief  features  in  the  differential  diagnosis 
are  found  in  the  physical  signs,  as  follows  : — 

Ovaritis                      vs.  Salpingitis. 

Lies  farther  from  the  uterus ;  Lies  nearer  the   uterus ;    more 

more  globular  in  shape.  elongated. 

Less  fluctuating  unless  abscess  More  fluctuating. 

present. 

The  ovary  cannot  be  felt  else-  The  ovary  can  often  be  felt  sepa- 

where.  rate  from  the  mass. 

How  would  you  differentiate  an  ovaritis  from  an  exudation 
in  the  broad  ligament? 

Ovaritis  vs.  Exudation  in  Broad  Ligament. 

More  circumscribed.  Less  circumscribed. 

Less  closely  related   to  vaginal      More  closely  related  to  vaginal 

vault.  vault. 

Less  fixity  of  the  uterus.  More  fixity  of  the  uterus. 

How  would  you  differentiate  ovaritis  from  a  lateral  uterine 
fibroid  ? 

Ovaritis  vs.  Lateral  Fibroid. 

Sensitive  to  pressure.  Insensitive  to  pressure . 
Less  intimately  connected  with      More  intimately  connected  with 

the  uterus.  the  uterus ;  moves  with  it. 

Density  less.  Density  greater. 

Menorrhagia  less  common.  Menorrhagia  more  common, 
12 


178  ESSENTIALS   OF   GYNECOLOGY. 

How  would  you  differentiate  ovaritis  from  faeces  in  the 
rectum? 

Ovaritis  vs.                       Faeces. 

More  sensitive.  Less  sensitive. 

G-lobular.  Elongated  in  shape. 

Does  not  indent  on  pressure.  Indents  on  pressure. 

Found  after  emptying  rectum.  Disappears  on  emptying  rectum. 

What  is  the  treatment  of  ovaritis  ? 

During  the  acute  stage  keep  patient  quiet  in  bed ;  apply  hot 
poultices  to  the  lower  abdomen ;  keep  bowels  open  and  faeces  soft ; 
give  an  anodyne,  if  necessary.  Later,  apply  counter-irritation  by 
means  of  iodine  to  the  vaginal  fornix  over  the  affected  organ,  and 
support  the  ovary  with  a  tampon.  An  excellent  method  is  to  soak 
a  roll  of  gauze  in  a  solution  of  iodoform  1  part,  chloral  1  part,  and 
glycerine  4  parts,  and  place  this  about  the  cervix,  especially  on  the 
affected  side.  After  the  withdrawal  of  this  support,  which  may  be 
left  in  twelve  to  twenty -four  hours,  a  hot- water  vaginal  douche  may 
be  used  with  advantage. 

As  a  last  resort,  after  a  faithful  trial  of  the  above  palliative 
measures  for  months  without  avail,  and  if  the  patient  is  a  great 
sufferer,  removal  of  the  offending  organ  by  laparotomy  is  indicated. 

If  abscess  of  the  ovary  is  present,  early  laparotomy  is  indicated. 

Prolapse  op  the  Ovary. 

What  is  the  etiology  and  pathology  ? 

Prolapse  of  the  ovary  may  occur  either  as  a  result  or  cause  of 
disease.  From  the  increase  in  size,  due  to  congestion  or  inflamma- 
tion, the  ovary  is  apt  to  prolapse. 

In  a  retroversion  or  retroflexion  of  the  uterus,  the  ovaries  also  are 
usually  drawn  backward,  and  from  their  disturbed  circulation  become 
congested  and  diseased.  In  their  descent  they  usually  first  lie  on 
the  retro-ovarian  shelves,  and  may  then  further  descend,  especially 
the  left,  into  the  pouch  of  Douglas. 

What  are  the  symptoms  ? 

They  are  those  of  ovaritis  and  of  ovarian  compression  ;  the  latter 
being  most  marked,  viz. :  painful  defecation  and  dyspareunia,  (The 
differential  diagnosis  has  been  given  under  ovaritis. ) 


AFFECTIONS   OF  THE  OVARIES.  179 

What  is  the  treatment  ? 

(a)  Palliative. — If  due  to  a  displacement  of  the  uterus  and  both 
uterus  and  ovaries  are  movable,  replace  the  uterus  and  maintain  it  in 
position  by  means  of  a  pessaiy. 

When  the  ovary  alone  is  displaced,  if  movable,  support  it  at  first 
with  a  tampon  ;  later  a  pessary  may  perhaps  be  worn. 

When  the  ovary  is  fixed  by  adhesions,  an  attempt  should  be  made 
to  cause  resolution  of  the  adhesions  by  counter-irritation,  glycerine  or 
boroglyceride  tampons,  hot- water  douches  and  gentle  massage. 

(b)  Radical. — If  the  palliative  measures  fail  and  the  symptoms 
are  severe,  a  laparotomy  is  indicated,  either  to  remove  the  prolapsed 
ovary,  or,  if  the  uterus  is  displaced  backward,  to  break  up  the  adhe- 
sions and  fasten  the  uterus  forward  by  hysterorrhaphy  or  by  short- 
ening the  round  ligaments. 

Tumors  of  the  Ovary. 
What  are  the  chief  varieties  ? 

(a)  Cysts. 

(b)  Carcinomata. 

(c)  Sarcomata. 

(d)  Fibromata. 

Tuberculosis  of  the  ovary  is  sometimes  described  under  tumors  of 
the  ovaiy. 

What  are  the  varieties  of  ovarian  cyst  ?    Describe  them. 

The  varieties  of  ovarian  cyst  are — 

The  simple  follicular. 
The  proliferating  glandular. 
The  proliferating  papillary. 
The  dermoid. 

The  simple  follicular  cyst  is  formed  by  distention  and  coalescence 
of  Graafian  follicles.  This  variety  of  cyst  is  usually  small,  often 
unilocular. 

The  proliferating  glandular  cyst  is  developed  from  the  "  glandular 
or  germinal  epithelium,  either  before  or  subsequent  to  the  formation 
of  tile  Graafian  follicles  "  (Howell).  This  is  the  ordinary  multiloc-u- 
lar  cyst  which  may  attain  a  large  size.     Within  one  main  cyst  thei  e 


180  ESSENTIALS   OF   GYNECOLOGY. 

may  be  several  secondary  or  daughter  cysts.  The  fluid  is  viscid, 
usually  greenish,  often  gelatinous. 

The  proliferating  papillary  cyst  is  developed  from  the  remains  of 
the  Wolffian  body  at  the  hilum  of  the  ovary.  On  the  interior  of  the 
cyst,  and  often  on  the  exterior,  are  papillae  or  villi  in  simple  or  com- 
pound form.  These  papillary  cysts  are  often  accompanied  by  ascites, 
often  infect  the  peritoneum,  and  often  become  malignant. 

The  dermoid  cyst  on  its  interior  seems  lined  with  skin.  It  may 
contain  hair,  sebaceous  matter,  teeth  or  irregular  fragments  of 
bone,  etc. 

The  present  accepted  idea  as  to  the  origin  of  dermoid  cysts  is  that 
they  are  caused  by  an  abnormal  inclusion  of  the  epiblast ;  i.  e. ,  that 
certain  misplaced  embryonic  cells  grow  within  the  ovary  and  produce 
the  tissue  to  which  they  were  destined. 

What  is  the  etiology  of  ovarian  cysts  ? 

Concerning  this  little  is  known.  They  occur  most  frequently  be- 
tween the  ages  of  20-50,  but  are  found  both  in  the  young  and  old. 

Simple  ovaritis  or  injury  of  the  ovary  are  said  by  some  to  predis- 
pose to  the  formation  of  a  cyst. 

What  changes  may  occur  in  an  ovarian  cyst  ? 

The  principal  changes  are  the  following  : — 

It  may  rupture,  usually  from  traumatism. 
Hemorrhage  may  occur  into  it. 
It  may  become  gangrenous  or  may  suppurate. 
The  hemorrhage,  gangrene  and  suppuration  are  usually  the  result 
of  torsion  of  the  pedicle. 

Suppuration  may  also  arise  from  the  introduction  of  sepsis  if  the 
tumor  is  tapped,  as  formerly  practiced. 

What  are  the  symptoms  of  an  ovarian  cyst  ? 

They  are  chiefly  those  of  pressure.  There  may  be  difficulty  in  urina- 
tion and  defecation  ;  in  the  later  stages  the  patient  is  greatly  ex- 
hausted by  the  great  weight,  and  often  suffers  with  dyspnoea. 

What  are  the  physical  signs  of  an  ovarian  cyst? 

These  vary  with  the  location.  When  small  and  in  the  pelvis  we 
get  a  tense  elastic  mass,  usually  fluctuating  and  insensitive  to  pres- 
sure. The  multilocular  variety  may  seem  hard.  The  uterus  is  dis- 
placed  by  the  tumor. 


AFFECTIONS   OF  THE  OVARIES.  181 

When  the  cyst  has  extended  to  the  abdomen,  we  get  distention  of 
the  abdomen  and  dullness  on  percussion  over  the  tumor.  Fluctua- 
tion can  usually  be  detected. 

From  what  must  you  differentiate  an  ovarian  cyst  when 
small  and  situated  in  the  pelvis  ? 
From  (a)  Distended  tube. 

(b)  Peritonitic  exudation. 

(c)  Inflammatory  exudation  into  broad  ligament. 

(d)  Extra-uterine  gestation. 

How  would  you  differentiate  a  small  ovarian  cyst  from  a  dis- 
tended tube  ? 

Ovarian  Cyst                 vs.  Distended  Tube. 

No  inflammatory  history;  gradual  History  of  acute  inflammation: 

development ;  little  if  any  pain.  pain  usually  prominent. 

More  globular.  More  elongated. 

Less  intimately  connected  with  More  intimately  connected  with 

the  uterus.  the  uterus. 

Insensitive  to  pressure.  Sensitive  to  pressure. 

Usually  lower  in  pelvis.  Usually  higher. 

Less  fixity.  More  fixity. 

How  would  you  differentiate  a  small  ovarian  cyst  from  a  peri- 
tonitic exudation  ? 

Ovarian  Cyst  vs.         Peritonitic  Exudation. 

No  history  of  acute  inflammation.       Histoiy  of  acute  inflammation. 
Insensitive.  Sensitive  to  pressure. 

More  mobile.  Fixed. 

More  lateral.  Usually  in  pouch  of  Douglas. 

How  would  you  differentiate  a  small  ovarian  cyst  from  an  ii?^ 
flammatory  exudation  into  the  broad  ligament  ? 

Ovarian  Cyst  vs.      Inflammatory  Exudation. 

Absence  of  history  of  inflamma-      History  of  inflammation  follow- 
tion.  ing  labor,  abortion,  or  opera- 

tion. If  a  hsernatorna,  history 
of  sharp  pain,  shock,  perhaps 
symptoms  of  hemorrhage. 


182 


ESSENTIALS  OP  GYNECOLOGY. 


More  mobile. 

Induration  of  parametrium  want- 


ing. 


Fixed. 
Induration  present. 

Sensitive  to  pressure. 
Bulges  more  into  vagina. 


Insensitive. 

Bulges  less  into  vagina. 

How  would  you  differentiate  an  ovarian  cyst  from  an  extra 
uterine  pregnancy  ? 
Ovarian  Cyst 
Slow  growth. 
No  symptoms  of  pregnancy. 


Menstruation    usually    not    far 

from  normal. 
More  mobile. 

Uterus  usually  not  enlarged. 
Pain   only   from    pressure ;    no 

acute  attacks. 


vs.       Extra- uterine  Pregnancy . 

Growth  more  rapid. 

Constitutional  symptoms  of  preg- 
nancy. 

Amenorrhoea  usually  followed  by 
menorrhagia. 

More  fixed. 

Uterus  enlarged. 

Attacks  of  pain  ;  finally  a  severe 
attack,  symptoms  of  shock  and 
hemorrhage. 

From  what  must  you  differentiate  a  large   ovarian  cyst 
occupying  the  abdomen? 
From  (a)  Pregnancy. 

(b)  Ascites. 

(c)  Fibroid  tumor  of  the  uterus. 

(d)  Distended  bladder. 

(e)  Haeinatoinetra. 

How  would  you  differentiate  a  large  ovarian  cyst  from  r 
pregnant  uterus  ? 

Ovarian  Cyst  vs.  Pregnant  Uterus. 


More  lateral. 
Menstruation  continues. 
Positive  symptoms  of  pregnancy 

absent. 
Uterus    small,     separate    from 

tumor ;  cervix  softened. 
Fluctuating. 


More  central. 

Amenorrhoea  the  rule. 

Positive  symptoms  of  pregnancy 

present. 
Uterus  forms  the  tumor  ;  cervix 

softened. 
Less    fluctuating ;    foetal    parts 

felt. 


AFFECTIONS   OF  THE   OVARIES.  183 

Intermittent  contractions  absent.       Intermittent    contractions    pre- 
sent. 
Growth  less  rapid.  Growth  more  rapid. 

How  would  you  differentiate  a  large  ovarian  cyst  from 
ascites  ? 

Ovarian  Cyst  vs.  Ascites. 

Patient  on  back  : —  Patient  on  back  : — 

Swelling  central  or  unilateral.  Swelling  bilateral. 

Dullness  in  front.  Tympanitic  in  front. 

Tympanitic  on  the  sides.  Dullness  on  the  sides. 

Percussion  note  varies  little  on      Percussion  note  varies  greatly  in 

turning  patient  from  side  to  turning  from  side  to  side. 

side. 
Circumscribed.  Diffuse. 

How  would  you  differentiate  a  large  ovarian  cyst  from  a 
large  fibroid  tumor  of  the  uterus  ? 

Ovarian  Cyst  vs.  Fibroid. 

Fluctuating.  Firm,  non-fluctuating. 

Less  intimately  connected  with      More  intimately  connected  with 

the  uterus.  the  uterus ;  moves  with  it. 

Menorrhagia  uncommon.  Menorrhagia  common. 

Uterus  usually  not  enlarged.  Uterus  usually  enlarged. 

How  would  you  differentiate  a  large  ovarian  cyst  from  a 
distended  bladder  ? 

Ovarian  Cyst  vs.  Distended  Bladder. 

More  lateral.  Central. 

Rarely  in  front  of  the  uterus.  Lies  in  front  of  the  uterus. 

Remains  after  patient  is  cathe-      Disappears     when     patient     is 
terized.  catheterized. 

How  would  you  differentiate  a  large  ovarian  cyst  from  a 
haematometra  ? 

Ovarian  Cyst  vs.  Hcematometra. 

Menstrual  flow  appears.  Menstrual  blood  retained. 

More  lateral;  separate  from  the      Central;  tumor  formed  by  the 
uterus.  distended  uterus. 


184  ESSENTIALS   OF  GYNECOLOGY. 

Pain  only  from  pressure.  Periodical  attacks  of  pain,  due  to 

increase  of  contents. 

Atresia  absent.  Atresia    of    vagina    or    cervix 

present. 

What  is  the  treatment  of  an  ovarian  cyst? 
The  only  treatment  is  removal  by  laparotomy. 

Parovarian  Cysts. 
Describe  briefly. 

They  are  cysts  developed  in  the  broad  ligament  from  the  parova- 
rium, the  remains  of  the  Wolffian  body.  These  cysts  are  usually, 
though  not  always,  unilocular;  the  contents  colorless,  thin  and 
watery.  The  cyst  wall  is  usually  thin,  and  fluctuation  very  distinct. 
As  the  cyst  grows,  it  opens  up  the  folds  of  the  broad  ligament. 

What  is  the  treatment  ? 

Removal  by  laparotomy  is  probably  the  best  treatment.  One  fold 
of  the  broad  ligament  is  incised  and  the  tumor  enucleated. 

They  were  formerly  treated  by  tapping,  but  there  is  danger  of 
sepsis  and  peritonitis,  and  they  often  refill. 

What  are  the  chief  points  in  the  technique  of  a  laparotomy 
for  the  removal  of  the  uterine  appendages  or  a  cyst  ? 

Have  the  bowels  of  the  patient  thoroughly  emptied,  and  allow 
only  fluid  diet  for  twenty-four  to  forty-eight  hours  preceding  the 
operation.  On  the  evening  before  the  operation,  it  is  well  to  thor- 
oughly wash  the  abdomen,  especially  about  the  umbilicus.  On  the  day 
of  the  operation,  the  abdomen  and  pubes  are  shaved,  scrubbed  with 
soap  and  water,  washed  with  alcohol,  and  then  with  bichloride  1-1 000. 

All  antiseptic  precautions  must  be  observed  in  regard  to  instru- 
ments, hands,  sponges,  etc. 

The  patient  having  been  anaesthetized,  a  final  cleansing  of  the 
abdomen  with  alcohol  and  bichloride  is  performed.  An  incision, 
about  three  inches  long,  is  made  in  the  median  line,  beginning  just 
below  the  umbilicus;  this  incision  is  deepened  to  the  peritoneum; 
bleeding  points  arc  clamped,  and  the  wound  irrigated  with  bichloride 
1-1000.  The  peritoneum  is  raised  with  thumb  forceps,  one  held 
by  the  operator,  the  other  by  an  assistant,  and  the  peritoneum  cut 
between  the  forceps;  the  incision  is  lengthened  with  the  scissors, 


AFFECTIONS   OF  THE  OVARIES.  185 

cutting  on  the  finger  to  the  length  of  the  abdominal  wound.  The 
latter  may  be  lengthened,  if  necessary. 

If  the  operation  is  for  the  removal  of  the  appendages,  the  fundus 
of  the  uterus  is  felt  for  as  a  landmark  ;  the  ovary  and  tube  of  the 
affected  side  are  brought  into  the  abdominal  wound  and  surrounded 
by  warm  sponges  or  pads.  A  Staffordshire  knot  (see  Fig.  57),  is 
tied  about  the  pedicle  ;  the  parts  outside  the  ligature  are  cut  away, 
the  stump  is  dusted  with  iodoform,  the  ligature  cut  short  and  the 
stump  dropped  back  into  the  abdominal  cavity.  The  other  side  is 
treated,  if  necessary,  in  the  same  way. 

If  the  operation  is  for  an  ovarian  cyst,  after  opening  the  abdomen 
the  cyst  is  punctured  with  a  trocar,  the  emptied  sac  drawn  out  of  the 
abdominal  wound,  the  adhesions  separated,  if  necessary,  the  pedicle 
tied  with  silk  in  a  Staffordshire  knot,  and  the  stump  treated  as  before, 

If  any  pus  has  gotten  into  the  abdominal  cavity,  the  latter  is  freely 
irrigated  with  hot  boiled  water,  and  a  glass  drainage  tube  inserted. 
If  no  irrigation  is  practiced,  the  tube  is  usually  omitted. 

The  abdominal  wound  is  closed  by  one  of  several  methods.  A  very 
good  one  is  to  use  silver  wire,  passing  through  skin,  muscle,  fascia 
and  peritoneum,  and  then  bring  the  skin  into  apposition  by  sutures 
of  silkworm  gut  introduced  between  the  silver  wires.  Some  suture 
the  peritoneum  separately,  but  this  is  unnecessary.  The  wound  is 
irrigated  with  bichloride,  1-1000 ;  iodoform  is  dusted  on  and  then 
a  dressing  of  iodoform  gauze,  bichloride  gauze  and  borated  cotton 
applied  and  held  in  place  by  plaster  strips  and  an  abdominal  binder. 
The  patient  is  then  put  to  bed  and  surrounded  with  hot-water  bottles. 

How  is  the  Staffordshire  knot  tied  ? 

FlG  57  The  suture  is  passed  from  you  through 

the  centre  of  the  pedicle  by  means  of  an 
aneurism  needle,  and  the  needle  with- 
drawn ;  the  loop  is  then  brought  forward 
over  the  tumor,  one  end  of  the  suture 
brought  above  and  the  other  left  below 
it  (see  Fig.  57).     The  two  ends  are  now 

STAFFORDSHIRE  KNOT  (7^)-         ^  fc  ft  fo^fe  ^    ^  fl  fl 

This  shows  knot  after  loop  has  * 

beer  brought  over,  one  end    the  pedicle  in  the  crease  formed  by  the 

brought    above  it,    and   the     <.  -\    ,•    j    •  j      t  1      1  ,i 

first  turn  of  the  artery  knot    loop  and  tied  m  a  double  knot  on  the 
made-  other  side. 


186  ESSENTIALS   OF  GYNAECOLOGY. 

What  is  the  after  treatment  of  the  case? 

The  patient  receives  no  food  by  the  mouth  for  12-24  hours,  nutri- 
ent enemata  being  used  in  the  meantime.  The  urine  is  drawn  with 
a  catheter.  As  little  opium  as  possible  is  used.  The  bowels  are 
moved  on  the  third  day  by  a  turpentine  enema,  calomel  gr.  iv  (g  -.  j 
eveiy  half  hour)  or  salines.  If  tympanites  occurs  at  any  time,  the 
bowels  are  moved 

The  stitches  are  removed  on  the  7-8th  day,  and  the  patient  is 
allowed  up  on  the  14th. 

How  would  you  prepare  catgut  for  ordinary  ligature  and 
suture  ? 

1.  Soak  the  gut  in  ether  for  1  hour. 

2.  Wipe  with  a  bichloride  towel. 

3.  Soak  in  bichloride  1  :  1000  for  8  hours. 

4.  Wipe  with  a  bichloride  towel. 

5.  Store  it  in  absolute  alcohol. 

How  would  you  prepare  the  chromicized  (McEwen's)  catgut  ? 
Soak  the  gut  for  48  hours  in  the  following  solution  : — 
B .     Acidi  chromici,  J  iij-  3  vss 

Aquae,  q.  s.  ad    Oj 

M.  et  adde 

Glycerini,  Ov. 

Then  store  the  gut  in  carbolized  glycerine  1-5. 
Wipe  with  a  bichloride  towel  before  using. 

Extra-Uterine  Gestation. 

What  are  the  varieties  ? 

Extra-uterine  gestation,  or  ectopic  gestation  (Tait),  may  present 
the  following  varieties  : — 

(a)  Tubal. — Growing  within  the  Fallopian  tube ;  this  is  the 
most  common  variety.  Three  varieties  of  tubal  gestation  are 
noticed  : — 

1.  Interstitial. — In  that  portion  of  the  tube  within  the  uterine 
wall. 

2.  In  the  tube  proper. 

3.  Tubo-ovarian . — Between  the  tube  and  ovary. 


EXTRA-UTERINE   GESTATION.  187 

(b)  Abdominal — This  was  probably  originally  tubal. 

(c)  Ovarian. — That  gestation  ever  occurs  within  the  ovary  is  very 
doubtful.     Tait  says  that  he  never  saw  such  a  case. 

What  is  the  etiology  ? 

Disease  of  the  tube,  or  obstruction  of  its  lumen  by  tumors, 
pressure,  or  traction  are  regarded  as  the  chief  causes. 

What  are  the  symptoms  ? 

There  is  usually  a  histoiy  of  previous  sterility  ;  then  symptoms  of 
early  pregnancy ;  usually  amenorrhoea  at  first,  later  irregular 
menstruation  or  menorrhagia.  Attacks  of  pain  with  symptoms  of 
shock  may  be  present ;  then  when  the  sac  ruptures,  symptoms  of 
hemorrhage,  severe  shock  and  collapse. 

What  are  the  physical  signs  ? 

The  uterus  is  found  somewhat  enlarged.  At  the  side  or  posterior 
a  tumor  is  felt,  tender  on  pressure,  and  containing  abundant  blood 
vessels.     Ballottement  is  sometimes  detected. 

What  is  the  course  and  result  ? 

Extra-uterine  pregnancy  is  usually,  if  not  always,  primarily  tubal. 
At  about  the  third  month  the  tube  usually  ruptures  either  into  the 
peritoneal  cavity  or  into  the  broad  ligament.  The  foetus  may  die  at 
this  time.  If  small,  it,  with  the  effused  blood,  may  be  absorbed  ;  if 
large,  it  may  become  encysted  and  retained  for  years,  or  suppuration 
may  occur  and  the  bones  be  extruded  through  the  rectum,  vagina, 
abdominal  wall,  or  bladder. 

The  foetus,  on  the  other  hand,  may  live,  the  placenta  being  attached, 
in  the  abdominal  variety,  to  the  abdominal  wall,  intestines  or  any  of 
the  viscera.  Tait  regards  the  extra-uterine  children  reaching  full 
term  as  in  the  broad  ligament. 

From  what  must  you  differentiate  extra-uterine  pregnancy  ? 

Suppurative  cellulitis. 
Fibroid  tumor. 
Ovarian  cyst. 
Dermoid  cyst. 
Parovarian  cyst. 
Salpingitis. 
Retroversio-flexio. 


188  ESSENTIALS   OF  GYNAECOLOGY. 

What  is  the  treatment  ? 

(A)  Before  the  viability  of  the  child,  two  views  are  held  at  the 
present  day : — 

1.  Perforin  laparotomy  as  soon  as  the  diagnosis  is  made,  and  re- 
move, if  possible,  the  foetus,  or  its  remains,  and  the  sac. 

2.  Destroy  the  life  of  the  foetus  by  electricity,  and  only  perform 
laparotomy  after  the  failure  of  nature  to  remove  the  products  of  ges- 
tation. 

Thomas  gives  as  a  rule  in  ectopic  gestation  prior  to  the  viability  of 
the  child  :  "A  diagnosis  of  extra-uterine  pregnancy  being  arrived 
at,  destroy  foetal  life  as  promptly  as  possible."  Of  several  methods 
of  accomplishing  this,  he  decidedly  prefers  electricity  without  acu- 
puncture. 

When  rupture  of  the  sac  into  the  peritoneal  cavity  occurs,  the 
usual  indication  is  to  perform  laparotomy  and  cleanse  the  abdominal 
cavity. 

(B)  After  the  viability  of  the  foetus,  the  best  rule  is  probably  to 
wait  till  full  term  and  perform  laparotomy,  with  the  hope  of  saving 
both  mother  and  child. 


Fistulse. 

What  are  the  chief  varieties  met  with  in  gynaecology  ? 
They  may  be  either  urinary  or  fecal. 
Urinary  fistulae  present  the  following  varieties  (see  Fig.  58) : — 

1.  Urethro-vaginal. 

2.  Vesico-vaginal. 

3.  Vesico-uterine. 

4.  Uretero-vaginal. 

5.  Uretero-uterine. 
The  most  common  is  the  vesico-vaginal. 

The  fecal  fistula  which  especially  concerns  us  is  the  recto-vaginal. 

What  is  the  etiology  of  a  vesico-vaginal  fistula  ? 

The  most  common  cause  is  sloughing  following  long-continued 
pressure,  usually  in  parturition,  but  occasionally  from  a  pessary.  It 
may  be  produced  by  direct  laceration  through  the  septum.  It  is  pre- 
disposed to  by  the  causes  of  a  tedious  labor. 


FISTULA. 


189 


What  are  the  symptoms  ? 

The  involuntary  escape  of  urine. 

A  urinous  odor  about  the  person. 

Irritation  and  excoriation  of  the  vulva  and  parts  around. 

How  is  the  diagnosis  made  ? 

If  the  fistula  is  not  evident  on  exposing  the  parts  with  a  Sims' 
speculum,  the  patient  being  in  Sims'  position,  the  bladder  may  be 
distended  with  some  colored  antiseptic  fluid,  like  creolin  solution, 
and  by  the  exit  of  the  latter  the  fistula  may  be  detected,  and  then 
verified  by  a  probe. 

Fig.  58. 


TO  REPRESENT   THE   CHIEF    VARIETIES   OF  URINARY    FISTULA — URETHRO-VAGINAD, 

Vesico-vaginal  and  Vesico-uterine. — Those  with  the  ureters  are  not,  seen. 
The  seat  of  a  recto-vaginal  fistula  is  indicated  (De  Sinety). 


What  is  the  treatment  ? 

The  treatment  usually  pursued  in  this  country  is  the  operation  of 
Sims,  which  is  performed  as  follows :  The  patient  is  anaesthetized, 
an  antiseptic  vaginal  douche  given,  and  all  antiseptic  precautions 
observed  during  the  operation.  She  is  placed  in  Sims'  position 
and  Sims'  speculum  introduced.  The  edges  of  the  fistula  are  pared 
with  the  knife  or  scissors,  the  mucous  membrane  not  being  included 
in  the  incision.  Silver-wire  sutures  are  then  introduced,  about  one- 
fifth  to  one-fourth  inch  apart,  not  penetrating  the  mucous  mem- 


190  ESSENTIALS   OF  GYNAECOLOGY. 

brane.  The  parts  are  brought  into  apposition  by  twisting  the  sutures, 
and  then  a  self-retaining  catheter  is  introduced.  The  sutures  are  left 
for  eight  days.  The  operation  for  a  urethro-vaginal  fistula  is  similar 
to  the  above. 

What  are  the  chief  steps  in  the  operation  for  the  cure  of  a 
vesico-uterine  fistula  ? 
Emmet  regards  the  condition  as  due  to  a  laceration  of  the  cervix 
extending  into  the  bladder,  the  laceration  healing  only  below.  The 
operation  is  based  on  this  idea,  viz. :  The  cervix  is  split  up  to  the 
fistula  ;  the  edges  of  the  latter  are  denuded,  and  the  whole  brought 
together  in  a  manner  similar  to  a  trachelorrhaphy,  especial  care  being- 
taken  with  the  upper  sutures.  If  this  fails,  it  has  been  recommended 
to  close  the  os  uteri;  this,  of  course,  causes  uterine  discharges  to 
empty  into  the  bladder. 


Recto-vaginal  Fistula. 

What  is  the  etiology  ? 

This,  like  the  vesico- vaginal  fistula,  is  usually  due  to  sloughing 
caused  by  long-continued  pressure  in  parturition,  or  may  be  produced 
by  laceration  through  the  septum,  either  by  the  unaided  efforts  of 
nature  or  by  instrumental  delivery.  Cancer  or  syphilis  may,  of 
course,  cause  fistula,  but  this  will  not  concern  us  here. 

What  is  the  treatment  ? 

It  is  similar  to  Sims'  operation  for  vesico-vaginal  fistula,  The 
edges  are  denuded  and  brought  together  by  silver  wire,  the  rectal 
mucous  membrane  being  uninjured.  If  the  fistula  is  near  the  vulva, 
it  is  usually  best  to  divide  the  sphincter  ani  and  perineum  up  to  the 
fistula,  to  dissect  this  out,  and  then  close  the  parts  as  in  a  laceration 
of  the  perineum  through  the  sphincter  ani. 


INDEX. 


A  LEXANDER'S  operation,  123 
-la-     Amenorrhoea,  96 
Atrophy  of  the  uterus,  151 

BIMANUAL  examination,  45 
Bladder,  35 
Bulbs  of  the  vagina,  20 

CARCINOMA  uteri,  167 
vJ     Cellulitis,  pelvic,  87 
Clitoris,  18 
Coccygodynia,  78 
Condylomata,  pointed,  74 

syphilitic,  75 
Curette,  61 

DEVELOPMENT  of  the  pelvic 
gans,  42 
Dilators,  57 

elastic,  61 

graduated,  hard,  59 
Displacements  of  the  uterus,  110 

anteflexion,  112 

anteversion,  111 

retroversion  and  retroflexion, 
Dysmenorrboea,  99 

ECZEMA  of  the  vulva,  72 
Emmet's  operation,  132 
Endometritis,  140 
acute,  141 
chronic,  142 
Erythema  of  the  vulva,  72 
Extra-uterine  gestation,  186 

FALLOPIAN  tubes,  30 
Fibroid  tumors  of  the  uterus, 
Fistula,  recto-vaginal,  190 
Fistulae,  ]88 
Fossa  navicularis,  20 
Fourchette,  20 


115 


151 


HEMATOCELE    and   haematoma. 
pelvic,  91 
Haematocele,  pudendal,  70 
Hemorrhage  from  vulva,  71 
Hernia,  pudendal,  69 
High  amputation  of  the  cervix,  170 
Hymen,  21 

Hyperesthesia  of  the  vulva,  77 
Hypertrophy  of  the  cervix,  134 
Hysterectomy,  vaginal,  169 
Hysterorrhaphy,  124 

INSTRUMENTS,  48 
A     Inversion  of  the  uterus,  158 
Irritable  urethral  caruncle,  79 
Ischio -rectal  fossa,  41 

LABIA  majora,  17 
minora,  18 
Laceration  of  the  perineum,  127 
of  the  cervix,  136 

MALFORMATIONS  of  the  uterus, 
106 
Malformations  of  the  vagina,  104 
atresia  of  the  vagina,  104 
of  the  vulva,  80 
Menstruation,  96 
disorders  of,  96 
amenorrhoea,  96 
dysmenorrhoea,  99 
obstructive,  100 
congestive,  100 
neuralgic,  101 
ovarian,  102 
membranous,  102 
menorrhagia  and  metrorrhagia,  98 
vicarious  menstruation,  98 
Metritis,  146 
acute,  147 
chronic,  148 
Mons  veneris,  17 


191 


192 


INDEX. 


"YTEW  growths  of  the  vulva,  74 


OVARIES,  31 
affections  of,  174 
hemorrhage  into,  174 
prolapse  of.  178 
tumor0  of,  179 
Ovaritis,  175 

PAPILLOMATA,  simple,  74 
Parovarian  cysts,  184 

Parovarium,  34 

Pelvic  floor,  39 

Perineal  body,  40 

Perineum,  muscles  of,  41 

Peritoneum,  pelvic,  84 

Peritonitis,  pelvic,  85 

Pessaries,  119 

Physical  examination  of  pelvic  organs, 
42 

Polypi,  163 

Probe,  uterine,  57 

Prolapse    of   urethral   mucous   mem- 
brane, 80 

Prolapsus  uteri,  124 

Pruritus,  vulval,  75 

Pudendal  hasmatocele,  70 
hernia,  69 

RECTAL  examination,  46 
Rectum,  37 

SAENGER-TAIT  operation,  128 
Salpingitis,  172 
Sarcoma  of  the  uterus,  171 
Skin  diseases  of  vulva,  72 


Sound,  uterine,  53 

Specula,  48 

Sims'  speculum,  48 
Fergusson's  speculum,  50 
Brewer's  speculum,  51 

Stenosis  of  the  cervix,  135 

HPENTS,  57 

J-      Trachelorrhaphy,  139 

URINARY  tract,  34 
Uterus,  23 
Uterus,  mucous  membrane  of,  25 

yAGINA,  21 
»       diseases  of,  81 
Vaginal  examination,  43 
Vaginismus,  77 
Vaginitis, 

simple  catarrhal,  81 

gonorrhceal,  82 

ulcerative,  83 

diphtheritic,  84 
Vestibule,  20 

Vicarious  menstruation,  98 
Volsella,  52 

Vulva,  malformations  of,  80 
Vulvitis,  62 

acute  simple  catarrhal,  63 

chronic  catarrhal,  63 

gonorrhoea],  64 

phlegmonous,  65 

diphtheritic,  66 

gangrenous,  66 

follicular,  67 
Vulvo- vaginal  glands,  21 

cyst  and  abscess  of,  68 


1VOVT    READY, 


Notes  on  the  Newer  Remedies 


THEIR 


THERAPEUTIC  APPLICATIONS 
AND  MODES  OF  ADMINISTRATION, 


BY 


DAVID  CEENA,  M.D.,  Ph.D., 

Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in  the 
University  of  Pennsylvania. 


FORMING  A  SMALL  OCTAVO  VOLUME  OF  ABOUT  175 

PAGES  (7  x  5)  INCHES. 

PRICE,        -        $1.&^. 

The  work  will  take  up  in  alphabetical  order  all  the  Newer  Reme- 
dies, giving  their  physical  properties,  solubility,  therapeutic  ap- 
plications, administration,  and  chemical  formula. 

It  will,  in  this  way,  form  a  very  valuable  addition  to  the  various 
works  on  Therapeutics  now  in  existence. 

Chemists,  are  so  multiplying  compounds  that  if  each  compound 
is  to  be  thoroughly  studied,  investigations  must  be  carried  far 
enough  to  determine  the  practical  importance  of  the  new  agents. 

Brevity  and  conciseness  compel  the  omission  of  all  biographical 
references. 


JUST  PUBLISHED. 


A  MANUAL 


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